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.

El carácter científico de la Cirugía. Historia y Filosofía / The Scientific Nature of Surgery. History and Philosophy

RESUMEN ¿Se puede hablar de ciencia cuando nos referimos a la cirugía? No, de acuerdo con la epistemología clásica, que dice que para que una disciplina sea considerada científica debe alcanzar requisitos que la cirugía parecería no cumplir. Esto es, ser parte de un paradigma y crear conocimiento científico. Por lo que, si queremos afirmar la cientificidad de la cirugía, debemos investigar la existencia de ejem plares que podrían ser paradigmáticos, ya que son ellos los que fundamentan su estructura epistémi ca. Junto a esto debemos demostrar que su práctica crea conocimiento científico. Para ello, postulamos cinco objetivos que la cirugía debe cumplir. Además, a los personajes históricos clásicos a quienes se les atribuye haber fundado la cirugía moderna ‒Ambrosio Paré y John Hunter‒, solo pudieron alcanzar los tres primeros. Pero esto no basta para que se considere a la cirugía como parte de la ciencia. Debimos avanzar en la historia y encontrar esos ejemplares paradigmáticos. El primero corresponde al trabajo de investigación en fase animal, previa a la realización de la primera gastrectomía exitosa rea lizada en seres humanos por el cirujano alemán Theodor Billroth, en el año 1882. El segundo corres ponde a la investigación en fisiología tiroidea realizada por Emil T. Kocher, con la que ganó el premio Nobel en Medicina y Fisiología en año 1909. Se hace un análisis del desarrollo epistémico de la cirugía a partir de ellos y se evalúan las consecuen cias mediante el concepto de ciclo epistémico. Hipótesis clave para entender la creación del conoci miento científico a partir de disciplinas técnicas como la cirugía.

ABSTRACT Can we talk about science when we speak about surgery? Not, accordingly to classical epistemology. To consider a discipline as scientific, it must meet certain requirements that surgery would not seem to satisfy: being part of a paradigm and creating scientific knowledge. Therefore, if we want to affirm the scientific nature of surgery, we must investigate the existence of exemplars that could be paradigmatic, since they are the ones that support its epistemic structure. Along with this, we must demonstrate that their practice creates scientific knowledge. We've postulated five objectives that surgery had to satisfy. We've seen in classic history, that the main characters which are considered founders of modern surgery -Ambrosio Pare and John Hunter- were only able to reach the first three, and as we'll see, were not enough to consider surgery as part of science. Moving forward in history, we are able to find the first paradigmatic exemplars. The first corresponds to the research work in the animal phase, prior to the first successful human gastrectomy performed by the German surgeon Theodor Billroth, in 1882. The second corresponds to the research in thyroid's physiology carried out by Emil T. Kocher; thanks to this, he won the Nobel Prize in medicine and phy siology in 1909. An analysis of the epistemic development of surgery is made from them, and the consequences are analyzed using the concept of the epistemic cycle. Those key hypotheses are important to understand the creation of scientific knowledge in technical disciplines as surgery.

Reconstruction of digestive tract with Billroth Ⅱ anastomosis in 4K laparoscopic distal radical gastrectomy / 中华消化外科杂志

Laparoscopic subtotal gastrectomy has become the main treatment of early gastric cancer. The 4K laparoscopic system has the advantage of enhancing the operator′s recognition of various anatomical levels and blood vessels in radical gastrectomy. The authors discussed the reconstruction of digestive tract with Billroth Ⅱ anastomosis in totally laparoscopic distal radical gastrectomy with the aid of 4K laparoscopic technique.

Reconstruction of digestive tract with Billroth Ⅰ anastomosis in 4K laparoscopic distal radical gastrectomy / 中华消化外科杂志

With the continuous improvement of laparoscopic surgery technology and equipment, the safety and long-term oncological results of laparoscopic distal gastrectomy for gastric cancer have been confirmed. In addition, due to the popularity of gastroscopy, the numbers of patient with early stage of gastric cancer or advanced stage of gastric cancer but mild condition is increasing. 4K laparoscopy has the advantages of large field of vision, high magnification and better display of local details which is helpful for lymph node dissection and anatomical identification. The author investigates the reconstruction of digestive tract with Delta anastomosis in 4K laparoscopic distal radical gastrectomy.

Overlap gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer / 中华胃肠外科杂志

Objective@#The aim of the current study is to compare the short-term clinical outcomes between Billroth-I reconstruction using an overlap method and delta-shaped anastomosis in totally laparoscopic distal gastrectomy (TLDG).@*Method@#A retrospective cohort study was performed. The following inclusion criteria were applied: (1) Preoperative gastroscopy and CT confirmed that the tumor is located in the antrum of the stomach, and the biopsy suggested adenocarcinoma; (2) Chest, abdomen and pelvis enhanced CT showed no evidence of distant metastasis; (3) Preoperative gastric reconstruction CT or endoscopic ultrasonography suggested that the clinical stage of the tumor is stage I-III. (4) During the operation, the tumor position was confirmed to be located in the antrum of the stomach by nanocarbon injection or gastroscope; (5) Complete laparoscopic radical gastrectomy for distal gastrectomy, and the gastrointestinal reconstruction was performed by delta-shaped anastomosis or overlap anastomosis. And the following exclusion criteria were applied: (1) History of gastric surgery; (2) Patients who cannot tolerate laparoscopic surgery because of comorbidities. Finally, data on 43 consecutive patients who underwent TLDG with Billroth-I reconstruction between January 2016 and November 2018 in Peking Union Medical College Hospital were retrospectively reviewed. Patients were divided into those who underwent Billroth-I reconstruction using an overlap method (n=20) or using delta-shaped anastomosis (n=23). The demographic and clinical characteristics and perioperative data of the two groups were analyzed. Measurement data that conformed to the normal distribution were expressed as the mean ± s, and differences between groups were compared using Student′s t-test; comparisons between the counting data groups were performed using the χ2 test or the continuously corrected χ2 test.@*Results@#The demographic and clinical characteristics were similar between the delta-shaped group and the overlap group (P>0.05). There was no significant difference between groups regarding operation time [(185.9±22.8) minutes vs. (184.0±25.8) minutes, t=0.260, P=0.796], blood loss [(50.9±36.0) ml vs. (47.0±30.8) ml, t=0.375, P=0.709], number of stapler reloads used for anastomosis (5.1±0.3 vs. 5.2±0.6, t=-0.465, P=0.651), time to flatus [(3.3±0.9) days vs. (3.6±0.9) days, t=-1.067, P=0.292) and postoperative hospitalization [(8.8±3.1) days vs. (10.4±3.8) days,t=-1.494, P=0.143]. As for the delta-shaped group and the overlap group, the anastomotic leakage rate was 4.3% (1/23) and 0 (χ2=0.000, P=1.000), respectively. The incidence of anastomotic bleeding was 4.3% (1/23) and 5.0% (1/20) (χ2=0.000, P=1.000), while the incidence of intra-abdominal hemorrhage was 4.3% (1/23) and 0 (χ2=0.000, P=1.000). The incidence of gastric emptying disorders was 4.3% (1/23) and 30.0% (6/20), respectively (χ2=3.454, P=0.063). All complications were cured after conservative treatment or symptomatic treatment.@*Conclusion@#The overlap method for Billroth-I reconstruction is safe and feasible.

Factors affecting ampullary access of ERCP after Billroth Ⅱ gastrectomy / 中华消化内镜杂志

Objective To investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy.Methods A retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017.Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access,and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors.Results A total of 345 ERCP sessions were collected.The successful ampullary access and cannulation rate were 82.3％ (284/345) and 89.1％ (253/284),respectively.The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3％,61/92) and failure of selective cannulation (33.7％,31/92).The ERCP-related complication rate was 14.2％ (49/345),with post-ERCP pancreatitis rate was 3.2％ (11/345).Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717,95％CI:2.581-23.068.P＜0.001),with Braun anastomosis (OR =8.737,95％CI:2.479-30.797,P =0.001),and no cap-assisted forward-viewing gastroscope (OR =2.774,95％ CI:1.283-5.997,P=0.009) were independent risk factors for failure of ampullary access.According to the B value of each risk factor in logistic regression analysis,that is,no cap-assisted as 1 point,the first ERCP attempt as 2 points,and Braun anastomosis as 2 points,the area under ROC curve was 0.773.When the cut-off point was 2.5,the sensitivity and specificity were 75.0％ and 70.8％,respectively.Conclusion The first ERCP attempt,with Braun anastomosis,and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients.Early identification of high-risk patients may help to improve the success rate of ampullary access.

Explore the value of ERCP in patients with choledocholithiasis after Billroth Ⅱ gastrointestinal anastomosis / 国际外科学杂志

Objective To explore the value of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis after Billroth Ⅱ gastrointestinal anastomosis.Methods A retrospective cohort study was conducted to retrospective review the data of 189 patients with choledocholithiasis treated by ERCP from December 2015 to November 2017 in Department of Hepatobiliary Surgery,Second Hospital of Hebei Medical University.According to the history of Billroth Ⅱ gastrointestinal anastomosis,the patients who have not undergone digestive surgery were divided into the normal group(n =167) and patients who have undergone digestive surgery were divided into reconstruction group (n =22).The operation time,the success rate of stone extraction,complications,the hospitalization time,total hospitalization expenses were compared between the two groups.Measurement data with normal distribution were represented as (Mean ± SD) and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were described as M (range).Comparisons of count data were analyzed using the x2 test or Fisher exact probability.Results The operation time of the normal group was (40.18 ± 11.80) min,and the success rate of ERCP was 97.60％ (163/167),the operation time of reconstruction group was(61.81 ± 13.21) min,and the success rate of ERCP was 81.82％ (18/22),There were significant differences between the two groups (t =0.105,x2 =10.400,P ＜ 0.05).The complications,the hospitalization time and the total hospitalization expense of the normal group were 16.17％ (27/167),(3.47 ± 1.55) d,(20 620.69 ± 3 117.88) yuan,the reconstruction group were 18.18％ (4/22),(4.18 ± 2.08) d,(22 426.41 ±5 916.30) yuan,with no statistically significant difference (x2 =0.000,t =4.204),t =10.828,P ＞ 0.05).Conclusions ERCP is safe and feasible for patients with choledocholithiasis after Billroth Ⅱ gastrointestinal anastomosis.It also has a high success rate of stone removal and small trauma,which is worthy of promotion.

Retrospective analysis of endoscopic retrograde cholangiopancreatography in patients with prior Billroth Ⅱ gastrectomy / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography ( ERCP ) in the treatment of patients with biliary and pancreatic diseases after Billroth Ⅱ gastrectomy. Methods Clinical data of 178 patients with biliary and pancreatic diseases undergoing 237 times of ERCP at the digestive endoscopy center in Changhai Hospital from January 2011 to December 2016 were retrospectively collected. The success rate of procedures and related complications were summed up. Results Among 178 patients undergoing 237 times of ERCP, the successful intubation rate of the endoscope to reach the duodenal papilla was 83. 5％ ( 198/237 ) . The success rate of selective cannulation and completing the expected intervention were 91. 4％ ( 181/198 ) and 98. 9％ ( 179/181 ) , respectively. The total success rate of ERCP was 75. 5％ (179/237), which had an increasing trend with time. The total success rate of ERCP in patients with common bile duct stone was 85. 2％ ( 127/149) , and the stone retrieval rate during the first session was 56. 7％ (72/127). The ERCP-related complication rate was 14. 3％ ( 34/237 ) , with 1. 7％ ( 4/237 ) perforation, 1. 3％ ( 3/237 ) bleeding, 3. 4％ ( 8/237 ) pancreatitis, and 8. 0％ ( 19/237 ) asymptomatic hyperamylasemia. One patient with perforation and 2 patients with severe pancreatitis died of septic shock and multiple organ failure ( 1. 3％, 3/237 ) . Most ERCP-related complications were improved by conservative treatment or second endoscopic intervention ( 91. 2％, 31/34 ) . Conclusion ERCP is effective and safe in the treatment of biliary and pancreatic diseases in patients with prior Billroth Ⅱ gastrectomy. With the development of endoscopic techniques and experience accumulation of endoscopists, the success rate of intubation, selective cannulation and therapeutic intervention can be close to those of patients with normal anatomy, and the incidence of related complications is low.

Roux-en-Y versus Billroth Ⅱ alimentary canal reconstruction after pancreaticoduodenectomy: a meta-analysis / 中华肝胆外科杂志

Objective To study the effectiveness and safety comparing Roux-en-Y versus Billroth Ⅱ alimentary canal reconstruction after pancreaticoduodenectomy (PD).Methods A computer search was conducted on PubMed,Embase,Web of Science,Science Direct,Springer Link,Cochrane Center,CBM,CNKI,Wan Fang and VIP databases before September 2017 for all RCT and CCT articles on Roux-en-Y versus Billroth Ⅱ reconstruction after PD.The quality of the included trials was studied by assessing the inclusive and exclusive criteria (the PRISMA statement) by 2 researchers independently.The data were extracted and analyzed using the RevManS.3 software.Results 9 articles (3 RCTs,6 CCTs) which involved 1 599 patients (563 Roux-en-Y patients,1 036 Billroth Ⅱ patients) were studied.Meta analysis revealed that Billroth Ⅱ patients had a lower postoperative delayed gastric emptying (DGE,grades B,C) rate (OR =3.76,95％ CI:1.32 ～ 10.68,P ＜ 0.05) and a shorter operation time (WMD =32.75,95％ CI:8.17 ～57.33,P ＜ 0.05) than Roux-en-Y patients.There were no significant differences in the rates of postoperative delayed gastric emptying (grades A,B,C),pancreatic fistula,bile leak,postoperative hemorrhage,reoperation,postoperative complications and the duration of postoperative stay (P ＞ 0.05).Conclusions The incidence of DGE (grades B,C) after PD was lower after Billroth Ⅱ than that of Roux-en-Y reconstruction.Large prospective randomized controlled trials are needed to confirm the findings of this meta-analysis.

Application of colonoscopy in treating choledocholith for patients with Billroth-Ⅱ gastroenterestomy / 中华肝胆外科杂志

A retrospective study was conducted based on the clinical data of 15 choledocholith patients after Billroth-Ⅱgastroenterestomy who were treated with endoscopic retrograde cholangio-pancreatography (ERCP) through colonoscopy or duodenoscopy.It showed that choledocholith removed by colonoscopy for patients with Billroth-Ⅱ gastroenterestomy can achieve comparable therapeutic effect,but this method can reduce the operation difficulty,shorten the operation time and significantly increase the success rate.

Theodor Billroth: pionero de la cirugía, intérprete, compositor y crítico musical / Theodor Billroth: Pioneer of surgery, performer, composer and music critic

Se analizan los hechos principales de la vida de Theodor Billroth, conocido padre y pionero de la cirugía. Billroth estudió Medicina por necesidad y presión familiar, pero su vocación primera fue siempre la música. Sin embargo, su carrera académica en la Cirugía fue sobresaliente, como profesor asociado de Cirugía en Berlín y luego en Zürich, llegando a ser nombrado jefe de departamento y decano en Viena. En su progresión académica destacó como pionero del desarrollo de la práctica quirúrgica y en el liderazgo en la formación de cirujanos y enfermeras. Paralelo a su progreso quirúrgico y académico, Billroth mantuvo su actividad musical como intérprete, compositor y crítico musical. En su desarrollo musical tuvo la poderosa influencia de Johannes Brahms, entre otros compositores, con quien desarrolló una fuerte amistad e intercambio de experiencias musicales.

Some of the main milestones in the life of Theodor Billroth are briefly analysed. Billroth, one of the pioneers of modern surgery studied Medicine because of family needs, but his first vocation was to be musician. Nevertheless, he developed a brilliant surgical career, leading the surgical progress and the training of surgeons and nurses. He was professor in Berlín, Zürich and Chief of Surgery and Dean in Viena. During his surgical life he maintained his musical dedication as performer, composer and music critic. The strong friendship with Johannes Brahms and others composers helped him to cultivate the musical art parallel to his surgical work.

Application of delta-shaped anastomosis in billroth-I reconstruction of totally laparoscopic distal gastric cancer radical operation / 重庆医学

Objective To evaluate the safety and short‐term efficacy of delta‐shaped anastomosis in the Billroth‐I reconstruc‐tion of totally laparoscopic distal gastric cancer radical operation (TLDG) .Methods The clinical data in 35 patients with TLDG Delta anastomosis(TLDG group) and 35 patients with laparoscopic assisted distal gastric cancer radical operation (LADG) extraper‐itoneal anastomosis (LADG group) in the gastroenterology department of our hospital from January to December 2014 were ana‐lyzed retrospectively .The intraoperative bleeding volume ,operative time ,gastroenterological function recovery time ,hospitalization duration ,postoperative pathological examination results and hospitalization total cost were compared between the two groups .Re‐sults Seventy cases successfully completed the operation without the cases of conversion to laparotomy and death .The TLDG group had no anastomotic leakage ,bleeding and stenosis after operation ;while the LADG group had 1 case of gastroparesis ,1 case of anastomotic bleeding and 2 cases of anastomotic leakage .The introperative bleeding volume ,tumor size ,number of lymph nodes dissection and distant and proximal incisal margin distance had no statistically significant differences between the two groups (P>0 .05);the operation time ,digestive tract reconstruction time ,first exhaustion time ,time taking liquid diet and postoperative hospital stay time in the TLDG group were significantly shorter than those in LADG group (P< 0 .05) ,but the hospitalization cost was higher than that in the LADG group ,the differences were statistically significant (P<0 .05) .Conclusion The delta‐shaped anasto‐mosis technique is safe and feasible for using in LADG ,moreover has better short‐term effect .

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.

Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

PURPOSE: Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY). MATERIALS AND METHODS: Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance. RESULTS: uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5+/-36.2 minutes for uDelta and 240.8+/-65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1+/-8.3 minutes vs. 38.0+/-9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2+/-1.9 days in the uDelta group and 7.2+/-0.8 days in the RY group (P=0.320). CONCLUSIONS: After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

Double-channel forward-view endoscopy for lower-position biliary obstruction after Billroth-Ⅱ gastrectomy / 中华消化内镜杂志

Objective To evaluate the clinical effects and safety of double-channel forward-view endoscopy for lower-position biliary obstruction after Billroth-Ⅱ gastrectomy.Methods A total of 18 patients with lower-position biliary obstruction after Billroth-Ⅱ gastrectomy were enrolled and treated with doublechannel forward-view endoscopy.The process and the outcomes were recorded.Effectiveness and safety were evaluated.Results Double-channel forward-view endoscopic treatment was successfully performed in 13 of the 18 patients (72％),with stone removal or stents implantion to resolve biliary obstruction.The procedure failed in 5 patients,who were transferred to surgery or underwent percutaneous transhepatic cholangial drainage.Delayed bleeding occurred in 1 patient,and pancreatitis in 2,who were cured after standard treatments.Conclusion Double-channel forward-view endoscopy is effective and safe for lower-position biliary obstruction in patients after Billroth-Ⅱ gastrectomy.

ERCP with double-channel endoscope for patients with Billroth-Ⅱ gastroenterostomy / 中华消化内镜杂志

Objective To evaluate the therapeutic effect and safety of forward-viewing,doublechannel endoscope in the process of ERCP in patients with bile duct diseases after Billroth-Ⅱ gastroenterostomy.Methods ERCP was applied to 46 patients with bile duct diseases using forward-viewing,doublechannel endoscope.All patients had the history of Billroth-Ⅱ gastroenterostomy.The success rate of selective cannulation,complication rate and the outcome of all the patients were recorded.Results The procedure succeeded in 38 patients with a success rate of 82.6％,and failed in 8.Of all the failing cases,the afferent loop couldn't be accessed in 6,failure in biliary cannulation in 2.Of 38 successful cases,bile duct stones were successfully removed in 31,metal stents placed for malignant bile duct obstruction in 4,and endoscopic balloon dilation for benign common bile duct stricture in 3.All patients recovered without complications of perforation,delayed bleeding or pancreatitis.Conclusion For patients with history of Billroth-Ⅱgastroenterostomy,ERCP with forward-viewing,double-channel endoscope yields to a higher success rate and lower complication rate.

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

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.