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.

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.

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 .

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.

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.

Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients / 대한외과학회지

PURPOSE: Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer. METHODS: Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diameter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastrointestinal series or endoscopy. RESULTS: Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with delayed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass index, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multivariate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040). CONCLUSION: In this study, the circular stapler diameter was one of the most significant predictable factors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gastric emptying associated with anastomosic stenosis or edema with relative safety.

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.

Delta-Shaped Gastroduodenostomy after Totally Laparoscopic Distal Gastrectomy: A Comparison Analysis between Early and Late Experience

PURPOSE: We conducted this study to evaluate the feasibility and the safety of a delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy (TLDG) and to know about the factors having influence on surgeons' performance of anastomosis and technical details of this operation. METHODS: The clinical characteristics and the surgical results of 57 consecutive patients with delta-shaped gastroduodenostomy after TLDG at Incheon St. Mary's Hospital were reviewed. The patients were divided into 2 groups (before and after 20 cases) and their clinical characteristics and surgical results were compared. The factors which influenced the anastomotic time and the technical details of the operation were also investigated. RESULTS: There was no difference in age, gender, body mass index, surgical results except for operation time, anastomotic time, and starting day of oral feeding between the 2 groups. The experience of the surgeon was the only factor that influenced the anastomotic time. CONCLUSION: Delta-shaped gastroduodenostomy is a feasible and safe procedure even in the early years of a surgeon's career. It could feasibly be done in less than 20 minutes in relatively experienced hands.

The Early Experience with a Laparoscopy-assisted Pylorus-preserving Gastrectomy: A Comparison with a Laparoscopy-assisted Distal Gastrectomy with Billroth-I Reconstruction

PURPOSE: Pylorus-preserving gastrectomy (PPG), which retains pyloric ring and gastric function, has been accepted as a function-preserving procedure for early gastric cancer for the prevention of postgastrectomy syndrome. This study was compared laparoscopy-assisted pylorus-preerving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGB I). MATERIALS AND METHODS: Between November 2006 and September 2007, 39 patients with early gastric cancer underwent laparoscopy-assisted gastrectomy in the Department of Surgery at Korea Cancer Center Hospital. 9 of these patients underwent LAPPG and 18 underwent LADGBI. When LAPPG was underwent, we preserved the pyloric branch, hepatic branch, and celiac branch of the vagus nerve, the infrapyloric artery, and the right gastric artery and performed D1+beta lymphadenectomy to the exclusion of suprapyloric lymph node dissection. The distal stomach was resected while retaining a 2.5~3.0 cm pyloric cuff and maintaining a 3.0~4.0 cm distal margin for the resection. RESULTS: The mean age for patients who underwent LAPPG and LADGBI were 59.9+/-9.4 year-old and 64.1+/-10.0 year-old, respectively. The sex ratio was 1.3:1.0 (male 5, female 4) in the LAPPG group and 2.6:1.0 (male 13, female 5) in the LADGBI group. Mean total number of dissected lymph nodes (28.3+/-11.9 versus 28.1+/-8.9), operation time (269.0+/-34.4 versus 236.3+/-39.6 minutes), estimated blood loss (191.1+/-85.7 versus 218.3+/-150.6 ml), time to first flatus (3.6+/-0.9 versus 3.5+/-0.8 days), time to start of diet (5.1+/-0.9 versus 5.1+/-1.7 days), and postoperative hospital stay (10.1+/-4.0 versus 9.2+/-3.0 days) were not found significant differences (P>0.05). The postoperative complications were 1 patient with gastric stasis and 1 patient with wound seroma in LAPPG group and 1 patient with left lateral segment infarct of liver in the LADGB I group. CONCLUSION: Patients treated by LAPPG showed a comparable quality of surgical operation compared with those treated by LADGBI. LAPPG has an important role in the surgical management of early gastric cancer in terms of quality of postoperative life. Randomized controlled studies should be undertaken to analyze the optimal survival and long-term outcomes of this operative procedure.

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.

Circular Stapled Billroth I Anastomosis after Distal Subtotal Gastrectomy : Anastomotic Complications and Prevention

PURPOSE: The circular stapled Billroth I gastrectomy has been gradually popularized because of several advantages. Thus, this study aims to identify what to be supplemented for the safety of this technique by examining the potential complication after the circular stapled Billroth I gastrectomy. MATERIALS AND METHODS: This study selected 594 patients who underwent the circular stapled Billroth I gastrectomy because of the gastric cancer in our department of surgery from Jan. 1998 to Dec. 2004 as the subjects. As of Jan. 2001 when the bleeding on the anastomosis site was visually checked through the small incision at the opposite curvature to the lesion of the stomach to be resected and so the operation was completed, the patients were divided into the Group I (n=219) and Group II (n=375), which were the patients before and after Jan. 2001, respectively. Then, the clinical characteristics and postoperative anastomotic complications of both groups were compared. RESULTS: For the comparison of complications between two groups, the anastomotic leakage was found in four cases in Group I and three cases in Group II (p=0.196). The stenosis on the anastomosis region was not observed in both groups. The bleeding on the anastomosis region illustrates the statistically significant difference between Group I and Group II, with 43 cases and 2 cases, respectively (P=0.019). CONCLUSION: The circular stapled Billroth I gastrectomy is recommended because of several advantages of this technique. However, the bleeding on the anastomosis site may be indicated as the critical issue. Accordingly, the visual check on the bleeding on the anastomosis site during the operation will improve the safety of circular stapler.

Comparison of the Early Postoperative Results after a Billroth I and a Billroth II Gastrectomy for Gastric Cancer

PURPOSE: The proper reconstructive technique after a partial gastrectomy for an adenocarcinoma of the stomach is often debated, but few data exist to clarify the issue. The aim of this study was to compare retrospectively the early postoperative results and complications after different anastomoses used during a partial gastrectomy for a gastric adenocarcinoma. MATENRIALS AND METHODS: We reviewed the hospital records of 218 patients who had undergone a subtotal gastrectomy for gastric cancer at Chosun University Hospital between January 1997 and July 2000. Of the 218 subtotal gastrectomies performed with curative intent, 127 reconstructions were Billroth I gastrectomies and 91 were Billroth II gastrectomies. The following data were analyzed: age, sex, tumor size, gastric resection margin, timing of removal of the nasogastric tube, first bowel movement, resumption of oral feeding, and postoperative complications. RESULTS: The timing of removal of the nasogastric tube was significantly earlier in the Billroth Igroup than in the Billroth II group (27.9+/-13.9 hours and 69.7+/-68 hours, respectively)(P<0.05). Resumption of oral feeding was possible on day 4.6+/-1.5 in the Billroth I group and on dsy 5.2+/-1.5 in the Billroth II group (P<0.05). There were no anastomotic leakage, postoperative bleeding, and postoperative mortality among the patients in either group. CONCLUSION: the Billroth Igastrectomy should be considered for patients undergoing a partial gastric resection for gastric cancer due to its physiological benefits and acceptable rate of complication.

Laparoscopy-assisted Billroth I Gastrectomy Compared with Hand-assisted Laparoscopic Surgery for Early Gastric Cancer -A Prospective Study-

PURPOSE: To compare standard laparoscopy-assisted Billroth I gastrectomies including standard lymph node dissection (LABIG) with hand-assisted laparoscopic surgery with the HandPort system (HALS) for the removal of early gastric cancers (EGC). METHODS: A prospective study was performed on 26 patients of EGC at Ewha Womans University Mok-Dong Hospital from July 1999 to August 2001. Seventeen patients (Group L) received LABIG using conventional laparoscopy-assisted methods and 9 patients received LABIG using HALS (Group H). We used staplers for the anastomosis, and a standard D2 lymph node dissection was done with ultrasonic shears or electrocautery. RESULTS: In group L, pathologic reports revealed 14 EGC (stage IA 14 cases), and 3 pm cancers (stage IB 1 case, II 2 cases). In group H, there were 9 early gastric cancers (stage IA 8 cases, IB 1 case). Significant differences (P<0.05) were present between group L and H in regards to the number of harvested lymph nodes (30.8 vs 18.9), estimated blood loss (462.1 vs 286.7 ml) and postoperative transfusion amounts (0.59 vs 0 unit). There were no differences in the mean operating time, distance from the lesion to the resection margin, postoperative leukocyte count, frequencies for pain control, wound size, time to diet, weight loss, serum protein, and postoperative hospital stay. Complications were present in 1 case in group L (enterocutaneous fistula) and 1 case in group H (gastric atony). There was one conversion to open surgery in group H. CONCLUSION: LABIG including standard lymph node dissections with both standard laparoscopic surgery and HALS were performed with equal outcome. The choice of surgical method depends on the characteristics of the lesion and the patient's physical factors.

Billroth I Anastomosis after a Radical Subtotal Gastrectomy The Safety of the Double-Stapling Method

PURPOSE: We compared the safety of the double-stapling method with that of the hand-sewn method when performing a Billroth I anastomosis (BI) after a radical subtotal gastrectomy. METHODS: Fifty-three (53) patients who received a BI with stapler from February 1998 to April 1999 were compared with 24 patients who received a BI with the hand-sewn method from January 1996 to December 1998. All the patients were divided into three groups according to the type of reconstruction: Group 1 (n=42), double- stapling method, Group 2 (n=11), anastomosis through posterior gastric wall, and Group 3 (n=24), hand- sewn method. The length of the greater curvature, lesser curvature, and proximal margin and the number of resected lymph nodes were compared for radicality, and the incidence of complications was reviewed. ANOVA and the chi-square test were used for the statistical analysis. RESULTS: The mean ages were 55.2+/-10.8, 59.8+/-9.7, and 54.7+/-11.9 years for groups 1, 2, and 3, respectively. The sex ratios were 2.2:1, 1.2:1, and 1.4:1. The lengths (cm) of the greater curvature were 17.2+/-2.5, 18.4+/-2.5, and 18.6+/-3.3, and the lengths of the lesser curvature were 10.4+/-1.5, 10.9+/-1.6, and 10.7+/-2.1; however, the differences were not statistically significant (p>0.05). The lengths of the proximal resection margin were 5.4+/-2.5, 8.2+/-3.3, and 6.0+/-3.2 (p<0.05), and the numbers of resected lymph nodes were 25.3+/-8.3, 19.1+/-5.8, and 32.+/- 13.7 (p<0.01). We experienced no complication in any group, except one case of leakage in the hand-sewn group. CONCLUSION: The double-stapling technique is a safe operative method in BI after a radical subtotal gastrectomy with its very low complication rate. Especially, the so- called Tornado method is a more useful method since it doesn't need a gastrotomy in the remnant stomach.

Billroth I Anastomosis after a Radical Subtotal Gastrectomy The Safety of the Double-Stapling Method

PURPOSE: We compared the safety of the double-stapling method with that of the hand-sewn method when performing a Billroth I anastomosis (BI) after a radical subtotal gastrectomy. METHODS: Fifty-three (53) patients who received a BI with stapler from February 1998 to April 1999 were compared with 24 patients who received a BI with the hand-sewn method from January 1996 to December 1998. All the patients were divided into three groups according to the type of reconstruction: Group 1 (n=42), double- stapling method, Group 2 (n=11), anastomosis through posterior gastric wall, and Group 3 (n=24), hand- sewn method. The length of the greater curvature, lesser curvature, and proximal margin and the number of resected lymph nodes were compared for radicality, and the incidence of complications was reviewed. ANOVA and the chi-square test were used for the statistical analysis. RESULTS: The mean ages were 55.2+/-10.8, 59.8+/-9.7, and 54.7+/-11.9 years for groups 1, 2, and 3, respectively. The sex ratios were 2.2:1, 1.2:1, and 1.4:1. The lengths (cm) of the greater curvature were 17.2+/-2.5, 18.4+/-2.5, and 18.6+/-3.3, and the lengths of the lesser curvature were 10.4+/-1.5, 10.9+/-1.6, and 10.7+/-2.1; however, the differences were not statistically significant (p>0.05). The lengths of the proximal resection margin were 5.4+/-2.5, 8.2+/-3.3, and 6.0+/-3.2 (p<0.05), and the numbers of resected lymph nodes were 25.3+/-8.3, 19.1+/-5.8, and 32.+/- 13.7 (p<0.01). We experienced no complication in any group, except one case of leakage in the hand-sewn group. CONCLUSION: The double-stapling technique is a safe operative method in BI after a radical subtotal gastrectomy with its very low complication rate. Especially, the so- called Tornado method is a more useful method since it doesn't need a gastrotomy in the remnant stomach.