Safety and efficacy of augmented-rectangle technique versus delta-shaped anastomosis for treating gastric cancer in total laparoscopic distal gastrectomy.

PURPOSE: This study aimed to evaluate the safety and efficacy of augmented-rectangle technique (ART) versus delta-shaped anastomosis (DA) for treating gastric cancer in total laparoscopic distal gastrectomy. METHODS: In total, 99 patients with distal gastric cancer who underwent ART (n = 60) or DA (n = 39) were considered. Operative data, postoperative recovery, complications, quality of life, and endoscopic findings of both groups were compared. RESULTS: The ART group had faster postoperative recovery than the DA group, and was better than DA regarding complications. The mode of reconstruction remained an independent predictor of complications, but not postoperative recovery. Dumping syndrome occurred in 3 (5.0%) and 2 patients (5.1%) of ART and DA groups within 30 days after surgery, and 3 (5.0%) and 2 patients (5.1%) 1 year after surgery. Regarding global health status on the EORTC-QLQ-C30 scale, the ART group had better outcomes than the DA group. Gastritis occurred in 38 (63.3%) and 27 (69.3%) patients of ART and DA groups, respectively. Residual food occurred in 8 (13.3%) and 11 (28.2%) patients of ART and DA groups. Reflux esophagitis occurred in 5 (8.3%) and 4 (10.3%) patients of ART and DA groups. Further, bile reflux occurred in 8 (13.3%) and 4 (10.3%) patients of ART and DA groups. CONCLUSIONS: ART has similar advantages to DA for total laparoscopic reconstruction and is superior to DA regarding the incidence of complications, complication grade, and global health status. Furthermore, ART may have potential advantages in postoperative recovery and anastomotic stenosis.

A new overlapped delta-shaped anastomosis technique using linear staplers with reinforced bioabsorbable material for intracorporeal anastomosis during laparoscopic colectomy.

AIM: Totally laparoscopic colectomy with intracorporeal anastomosis (IA) is associated with less surgical trauma and wound related complications compared to laparoscopy-assisted colectomy with extracorporeal anastomosis. Delta shaped anastomosis is a widely popular IA technique. In this study, we discuss a construction technique for an overlapped delta-shaped anastomosis using a linear stapler with a reinforced bioabsorbable material. METHODS: We excised the bowel at a point 10 cm from the tumour on either sides and laid them in an overlapped fashion. The entry hole was created at a point 3 cm proximal to the right stump and 7 cm distal to the left stump on the antimesenteric side. Then, a 60-mm linear stapler with reinforced bioabsorbable material was inserted inside each lumen and fired. Finally, the common entry hole was fixed with a suture in the middle, the bowel was elevated holding the bioabsorbable material, and closed using the linear stapler in a delta-shaped manner. RESULTS: The technique was applied in five patients with tumours in the ascending, transverse, and descending colon. The median surgery time, anastomosis construction time and postoperative stay was 329 min (range 285-682 min), 19 min (range 14-29 min), and 12 days (range 9-15 days), respectively. There were no perioperative complications and only one postoperative complication. CONCLUSION: The overlapped delta-shaped anastomosis technique using linear staplers with reinforced bioabsorbable material appears to be both safe and feasible.

[Safety and feasibility of overlapped delta-shaped anastomosis technique for digestive tract reconstruction during complete laparoscopic right hemicolectomy].

Objective: To explore the clinical safety and feasibility of overlapped delta-shaped anastomosis (ODA) in totally laparoscopic right hemicolectomy (TLRHC). Methods: From May 2017 to October 2019, of the 219 patients who underwent TLRHC at the Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 104 cases underwent ODA (ODA group) and 115 cases underwent conventional extracorporeal anastomosis (control group) were compared the surgical outcomes, postoperative recovery, pathological outcomes and perioperative complications. Results: The length of the skin incision in the ODA group was significantly shorter than that in the control group [(5.6±0.9) cm vs. (7.1±1.7) cm, P<0.05], and the time to first flatus and first defecation after surgery in the ODA group was significantly earlier than that in the control group [(1.7±0.7) days vs. (2.0±0.7) days; (3.2±0.6) days vs. (3.3±0.7) days, P<0.05]. While the anastomosis time, operation time, intraoperative blood loss, the time of first ground activities, the number of bowel movements within 12 days after surgery, postoperative hospital stay, tumor size, the distal and proximal margins, the number of lymph node harvested and postoperative TNM stage in the ODA group did not differ from that of the control group (P>0.05). The postoperative complication rates of patients in the ODA group and the control group were 3.8% (4/104) and 4.3% (5/115), respectively, and the difference was not significant (P>0.05). Conclusion: The application of ODA technology in TLRHC can significantly shorten thelength of skin incisionand the recovery time of bowel function, and can obtain satisfactory short-term efficacy.

Impact of the indocyanine green fluorescence method for anastomotic blood flow in robotic distal gastrectomy.

PURPOSE: To evaluate the blood flow at the site of delta-shaped anastomosis during robotic distal gastrectomy and determine surgical outcomes and risk factors for ischemia at the anastomotic site from the perspective of clinical characteristics, surgical outcomes and perigastric vascular anatomy. METHODS: We included 55 patients who underwent robotic distal gastrectomy with a blood flow evaluation in the duodenal walls using intravenous indocyanine green injection with the da Vinci Xi-equipped Firefly system. Additional resection was performed in patients with a poor blood flow. Clinical characteristics, surgical outcomes and perigastric vascular anatomy were compared between the 45 patients with sufficient blood flow (group S) and the 10 patients with insufficient blood flow (group I). Vascular anatomy was assessed by preoperative contrast-enhanced computed tomography according to Hiatt's classification. RESULTS: The patient characteristics and surgical outcomes were not significantly different. No patient developed anastomotic complications requiring intervention; more patients in group I had aberrant branching of the left hepatic artery than those in group S (p = 0.047). CONCLUSIONS: An indocyanine green-based blood flow evaluation might be an effective method of preventing anastomotic complications of delta-shaped anastomosis. Anatomical branching variations of the left hepatic artery might be a risk factor for impaired vascular perfusion of the anastomotic site.

Safety and feasibility of overlapped delta-shaped anastomosis technique for digestive tract reconstruction during complete laparoscopic right hemicolectomy / 中华肿瘤杂志

Objective: To explore the clinical safety and feasibility of overlapped delta-shaped anastomosis (ODA) in totally laparoscopic right hemicolectomy (TLRHC). Methods: From May 2017 to October 2019, of the 219 patients who underwent TLRHC at the Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 104 cases underwent ODA (ODA group) and 115 cases underwent conventional extracorporeal anastomosis (control group) were compared the surgical outcomes, postoperative recovery, pathological outcomes and perioperative complications. Results: The length of the skin incision in the ODA group was significantly shorter than that in the control group [(5.6±0.9) cm vs. (7.1±1.7) cm, P<0.05], and the time to first flatus and first defecation after surgery in the ODA group was significantly earlier than that in the control group [(1.7±0.7) days vs. (2.0±0.7) days; (3.2±0.6) days vs. (3.3±0.7) days, P<0.05]. While the anastomosis time, operation time, intraoperative blood loss, the time of first ground activities, the number of bowel movements within 12 days after surgery, postoperative hospital stay, tumor size, the distal and proximal margins, the number of lymph node harvested and postoperative TNM stage in the ODA group did not differ from that of the control group (P>0.05). The postoperative complication rates of patients in the ODA group and the control group were 3.8% (4/104) and 4.3% (5/115), respectively, and the difference was not significant (P>0.05). Conclusion: The application of ODA technology in TLRHC can significantly shorten thelength of skin incisionand the recovery time of bowel function, and can obtain satisfactory short-term efficacy.

Comparison of delta-shaped anastomosis and Billroth I reconstruction after laparoscopic distal gastrectomy for gastric cancer.

BACKGROUND: This study intends to compare the short-term effects and long-term survival of gastric cancer patients who underwent delta-shaped anastomosis (DA) and Billroth I reconstructions after laparoscopic distal gastrectomy. METHODS: We retrospectively collected data from 257 patients with gastric cancer who underwent laparoscopic distal gastrectomy between January 2013 and December 2017. Patients were classified into 2 groups according to the reconstruction method used: the DA group (n=91) and the Billroth I group (n=166). The clinical data, short-term efficacy, and long-term results were compared between the 2 groups. RESULTS: The operation time (P<0.001) and the post-operative length of hospital stay (P<0.001) were shorter in the DA group than in the Billroth I group. The time to the first oral intake of a soft diet after surgery was earlier in the DA group than in the Billroth I group (P=0.014). Kaplan-Meier (log-rank test) analysis showed no significant difference in the 5-year survival rates between the 2 groups for patients at the same pathological stage. Multivariate analysis showed that abnormal carcinoembryonic antigen (CEA) (P=0.006), chemotherapy (P<0.001), T stage (P<0.001), and N stage (P<0.001) were independent prognostic factors for survival. CONCLUSIONS: DA and Billroth I are feasible and safe reconstruction methods of the digestive tract after gastric cancer. DA is the recommended reconstruction method for laparoscopic distal gastrectomy.

[Analysis of short-term efficacy of overlapping delta-shaped anastomosis in totally laparoscopic left hemicolectomy for digestive tract reconstruction].

Objective: At present, though the laparoscopic delta-shaped anastomosis and overlapping delta-shaped anastomosis have been gradually applied to complete laparoscopic radical resection of left hemicolon cancer, the comparative evaluation of their efficacy has not been mentioned in the published literatures. This study aims to explore the safety, feasibility and short-term efficacy of overlapping delta-shaped anastomosis (ODA) in totally laparoscopic left hemicolectomy. Methods: A retrospective cohort study was performed. The clinical and pathological data of patients who underwent totally laparoscopic left hemicolectomy at Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from May 2017 to October 2020 were retrospectively analyzed. The case inclusion criteria were as follows: (1) age of 18-75 years; (2) body mass index (BMI) of 18.5-30 kg/m(2); (3) descending colonic and proximal sigmoid colonic adenocarcinoma was confirmed by preoperative colonoscopy and pathology. The exclusion criteria: (1) multiple primary colorectal cancers; (2) uncontrolled or poorly controlled diabetes mellitus, immune system diseases, or hematological diseases; (3) severe intestinal obstruction; (4) left transverse colonic or splenic flexure colonic adenocarcinoma; (5) distant metastasis of liver, lung and other viscera determined by enhanced computed tomography in the chest, abdomen and pelvis. According to the above criteria, a total of 115 patients with left hemicolon cancer were enrolled. All the patients underwent totally laparoscopic left hemicolectomy. Patients who underwent laparoscopic traditional delta-shaped anastomosis were selected as the control group. Patients who underwent laparoscopic ODA were selected as the ODA group. Effects of these two laparoscopic reconstruction methods on postoperative recovery and perioperative complications were analyzed and compared. Results: A total of 60 patients were enrolled in the ODA group, including 32 males and 28 females, with mean age of (57.3±10.4) years and body mass index (BMI) of (25.0±3.1) kg/m(2). While mean 55 patients were enrolled in the control group, including 31 males and 24 females, with mean age of (56.7±9.9) years and BMI of (24.4±2.9) kg/m(2). There was no statistically significant differences between the two groups in gender, age, BMI, American Society of Anesthesiologist (ASA) classification, TNM staging, preoperative abdominal surgery history, neoadjuvant chemotherapy and nutritional status (levels of hemoglobin, lymphocyte count, prealbumin, and albumin) (all P>0.05). All the patients in both groups received R0 resection without conversion to open laparotomy or conversion to extra-abdominal anastomosis. The digestive tract reconstruction time of the ODA group was significantly shorter than that of the control group [(15.1±1.7) minutes vs. (15.9±2.4) minutes, t=-2.053, P=0.042]. There were no statistically significant differences in the total operation time, intraoperative blood loss, length of skin incision, tumor size, proximal and distal margins, harvested lymph nodes, postoperative first ambulatory time, and postoperative hospital stay (all P>0.05). However, the time to the first flatus and the first defecation in the ODA group was significantly shorter as compared to control group [(1.5±0.5) days vs. (1.7±0.5) days, t=-2.028, P=0.045; (3.1±0.6) days vs. (3.4±0.7) days, t=-2.095, P=0.039], indicating faster intestinal function recovery in patients with ODA. The morbidity of postoperative complication was 6.7% (4/60) in the ODA group and 7.3% (4/55) in the control group and no significant difference was found (χ(2)=0.016, P=0.898). Two cases of incision infection, 1 case of lung infection, and 1 case of intra-abdominal infection occurred in the ODA group, while 3 cases of lung infection and 1 case of intra-abdominal infection occurred in the control group. All these complications were resolved after conservative treatment, and no secondary operation was performed due to complications. Conclusion: Compared with the traditional delta-shaped anastomosis, ODA is associated with a faster recovery of postoperative intestinal function without increasing the morbidity of postoperative complications, and has the satisfactory short-term efficacy.

The safety and feasibility of intra-corporeal gastroduodenostomy using a self-pulling and latter transected method (Delta SPLT) in totally laparoscopic distal gastrectomy.

BACKGROUND AND OBJECTIVES: In 2016, the self-pulling and latter transection method (named "Delta SPLT"), a modified delta-shaped gastroduodenostomy (DA) technique for totally laparoscopic distal gastrectomy, was described. Delta SPLT reduced the technical difficulty of the surgery and the quantity of cartridges required with a manageable initial safety profile. Here, the safety and feasibility of this technique are analyzed at 1 year's follow-up. METHODS: The demographic and clinicopathologic profiles, perioperative details, and postoperative outcomes of 45 consecutive patients who underwent Delta SPLT from March 2016 to March 2019 were retrospectively analyzed. The Delta SPLT technique, which consisted of one endoscopic linear stapler and four cartridges each, was used for reconstruction in every case. RESULTS: The mean operative time was 127.1 ± 38.2 min, including a reconstruction duration of 22.6 ± 7.2 min. There were no surgical or anastomotic complications. The mean postoperative stay duration was 5.8 ± 1.2 days, and the morbidity rate was 2.2% with one case of postoperative pneumonia. CONCLUSIONS: The results at the one-year follow-up suggest that Delta SPLT is a safe and feasible procedure. Delta SPLT is characterized by fewer difficulties experienced during surgery, lower surgical costs, it is easy to practice, and it is beneficial for patients who are undergoing gastroduodenostomy.

Modified Delta-shaped Anastomosis via the Overlap Method Using Linear Staplers for Colon Cancer.

Here, we describe the modified delta-shaped anastomosis (DSA) via the overlap method and how it was a beneficial intracorporeal anastomotic technique for four patients who underwent laparoscopic colectomy. After resecting the colon on both sides of the lesion, proximal and distal colon were laid in an overlap fashion and fixed using sutures. The entry hole was created using an ultrasound scalpel at a point 3 cm proximal to right colic stump and 7 cm distal to left colic stump on the anti-mesenteric side. Then, two arms of the linear stapler were inserted inside each lumen and fired. Finally, using the linear stapler, the common entry hole was closed in a delta-shaped manner. The mean duration of surgery was determined to be 218.4 (196-369) minutes, and amount of blood loss was measured to be 11 (5-25) mL. No intraoperative and postoperative complications were observed. Median postoperative hospital stay was 12 days. Thus, modified DSA via overlap method can be considered as a safe and simple IA technique.

Delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy for gastric cancer: comparative study of original and modified methods.

BACKGROUND: Delta-shaped anastomosis (DA) has been widely accepted as a standard procedure for intracorporeal Billroth-I reconstruction after laparoscopic distal gastrectomy. We introduced DA in 2010 at our hospital and later developed a modified DA method in which a stapled corner of the duodenal stump was removed simultaneously with closure of an entry hole to reduce postoperative complications. METHODS: The clinical data of 507 patients undergoing laparoscopic distal gastrectomy with DA from October 2010 through December 2018 were retrospectively collected from our in-house database. On the basis of the reviewed data, patients were divided into two groups: the original DA group (org-DA, n = 392) and the modified DA group (mod-DA, n = 115). Surgical outcomes, postoperative nutritional parameters, and endoscopic findings 1 year after surgery were compared between the two groups. RESULTS: Baseline characteristics were similar between the two groups. Anastomotic stricture occurred in three patients (0.8%) in the org-DA group and one patient (0.9%) in the mod-DA group (P = 0.911). Anastomotic leakage was recorded in five patients (1.3%) in the org-DA group and none of the patients (0%) in the mod-DA group (P = 0.593). One year after surgery, the change in body weight in the org-DA group/mod-DA group was - 8.1%/- 7.0% (P = 0.285), and the change in hemoglobin level was - 5.0%/- 3.9% (P = 0.012). Endoscopic examination at the 1-year follow-up in the mod-DA group showed smaller amounts of food residue (P = 0.008) as well as less residual gastritis (P < 0.001) than in the org-DA group. CONCLUSIONS: The modified DA method can be performed safely with a complication rate comparable with the original DA method. Furthermore, better postoperative function is expected because of its more natural anatomy and physiology resulting from the modified method.

Functional Outcomes of Delta-Shaped Anastomosis After Laparoscopic Distal Gastrectomy.

BACKGROUND: We invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings. METHODS: The medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings. RESULTS: The operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only. CONCLUSIONS: Functional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

Comparison of Clinical Effects between Modified and Conventional Delta-Shaped Anastomosis in Totally Laparoscopic Distal Gastrectomy: A Retrospective Study.

Background: This study evaluates the feasibility, safety, and clinical results of the self-pulling and latter transected delta-shaped anastomosis (Delta SPLT) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. Methods: We performed a retrospective study of 66 patients with gastric cancer undergoing laparoscopic distal gastrectomy with Billroth-I anastomosis from May 2017 to December 2018 in Zhoushan Hospital. TLDG with Delta SPLT was carried out in 26 patients (Group 1), and TLDG with conventional delta-shaped anastomosis (DA) was performed in 40 patients (Group 2). Statistical analysis was conducted to compare clinical data between the two groups. Results: All patients successfully underwent TLDG. There were no significant differences between the two groups in terms of demographic indicators, operation time, anastomosis time, intraoperative blood loss, number of lymph nodes harvested, and resection margin (all P > .05). The gastrointestinal functional evaluation index (first flatus, first liquid/semigeneral diet foods, and out-of-bed mobilization) and hospital stay did not differ between the two groups, but the mean hospital charges were significantly lower in Group 1 than in Group 2 (P < .05). No difference was observed in the overall postoperative complication rate (P > .05). However, Group 1 had a lower incidence of complications associated with anastomosis (3.8%, versus 7.5% in Group 2; P = .016). Conclusions: Delta SPLT is potentially a safe, feasible, and reproducible reconstruction option for TLDG, and was superior to conventional DA in terms of hospital charges and complications related to anastomosis.

Analysis of short-term efficacy of overlapping delta-shaped anastomosis in totally laparoscopic left hemicolectomy for digestive tract reconstruction / 中华胃肠外科杂志

Objective: At present, though the laparoscopic delta-shaped anastomosis and overlapping delta-shaped anastomosis have been gradually applied to complete laparoscopic radical resection of left hemicolon cancer, the comparative evaluation of their efficacy has not been mentioned in the published literatures. This study aims to explore the safety, feasibility and short-term efficacy of overlapping delta-shaped anastomosis (ODA) in totally laparoscopic left hemicolectomy. Methods: A retrospective cohort study was performed. The clinical and pathological data of patients who underwent totally laparoscopic left hemicolectomy at Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from May 2017 to October 2020 were retrospectively analyzed. The case inclusion criteria were as follows: (1) age of 18-75 years; (2) body mass index (BMI) of 18.5-30 kg/m(2); (3) descending colonic and proximal sigmoid colonic adenocarcinoma was confirmed by preoperative colonoscopy and pathology. The exclusion criteria: (1) multiple primary colorectal cancers; (2) uncontrolled or poorly controlled diabetes mellitus, immune system diseases, or hematological diseases; (3) severe intestinal obstruction; (4) left transverse colonic or splenic flexure colonic adenocarcinoma; (5) distant metastasis of liver, lung and other viscera determined by enhanced computed tomography in the chest, abdomen and pelvis. According to the above criteria, a total of 115 patients with left hemicolon cancer were enrolled. All the patients underwent totally laparoscopic left hemicolectomy. Patients who underwent laparoscopic traditional delta-shaped anastomosis were selected as the control group. Patients who underwent laparoscopic ODA were selected as the ODA group. Effects of these two laparoscopic reconstruction methods on postoperative recovery and perioperative complications were analyzed and compared. Results: A total of 60 patients were enrolled in the ODA group, including 32 males and 28 females, with mean age of (57.3±10.4) years and body mass index (BMI) of (25.0±3.1) kg/m(2). While mean 55 patients were enrolled in the control group, including 31 males and 24 females, with mean age of (56.7±9.9) years and BMI of (24.4±2.9) kg/m(2). There was no statistically significant differences between the two groups in gender, age, BMI, American Society of Anesthesiologist (ASA) classification, TNM staging, preoperative abdominal surgery history, neoadjuvant chemotherapy and nutritional status (levels of hemoglobin, lymphocyte count, prealbumin, and albumin) (all P>0.05). All the patients in both groups received R0 resection without conversion to open laparotomy or conversion to extra-abdominal anastomosis. The digestive tract reconstruction time of the ODA group was significantly shorter than that of the control group [(15.1±1.7) minutes vs. (15.9±2.4) minutes, t=-2.053, P=0.042]. There were no statistically significant differences in the total operation time, intraoperative blood loss, length of skin incision, tumor size, proximal and distal margins, harvested lymph nodes, postoperative first ambulatory time, and postoperative hospital stay (all P>0.05). However, the time to the first flatus and the first defecation in the ODA group was significantly shorter as compared to control group [(1.5±0.5) days vs. (1.7±0.5) days, t=-2.028, P=0.045; (3.1±0.6) days vs. (3.4±0.7) days, t=-2.095, P=0.039], indicating faster intestinal function recovery in patients with ODA. The morbidity of postoperative complication was 6.7% (4/60) in the ODA group and 7.3% (4/55) in the control group and no significant difference was found (χ(2)=0.016, P=0.898). Two cases of incision infection, 1 case of lung infection, and 1 case of intra-abdominal infection occurred in the ODA group, while 3 cases of lung infection and 1 case of intra-abdominal infection occurred in the control group. All these complications were resolved after conservative treatment, and no secondary operation was performed due to complications. Conclusion: Compared with the traditional delta-shaped anastomosis, ODA is associated with a faster recovery of postoperative intestinal function without increasing the morbidity of postoperative complications, and has the satisfactory short-term efficacy.

Systemic steroid application for treatment of edematous anastomotic stenosis following delta-shaped anastomosis in laparoscopic distal gastrectomy: a case report.

BACKGROUND: Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation. CASE PRESENTATION: We present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment. CONCLUSION: Systemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.

[Short-term efficacy of totally laparoscopic left colon cancer radical resection with overlapped delta-shaped anastomosis technique].

Objective: To evaluate the safety, feasibility and short-term efficacy of totally laparoscopic left colectomy for left colon cancer by using overlapped delta-shaped anastomosis technique for digestive tract reconstruction. Methods: A retrospective cohort study was conducted to collect the clinical data of 86 patients with left colon cancer who underwent laparoscopic surgery in Cancer Hospital of Chinese Academy of Medical Sciences from October, 2017 to February, 2019. The patients were divided into totally laparoscopic left-sided colectomy (TLLC) (treatment group, n=25 cases) and laparoscopic-assisted left-sided colectomy (LALC) (control group, n=61 cases). The intraoperative and postoperative data were compared between the two groups. Results: There were no surgical-related deaths in both groups. All the patients in the TLLC group underwent laparoscopic resection, while one patient in the LALC group transfer to open surgery. The operation time in TLLC group and LALC group were (164.5±42.3) min and (171.0±43.1) min, respectively, without statistically significant difference (P=0.516). However, the intraoperative blood loss of patients in the TLLC group was (36.4±22.7) ml, which was significantly less than (52.9±32.2) ml in the LALC group (P=0.026). The anastomosis time in the TLLC group was (39.1±6.5) min, which was significantly longer than (24.9±5.4) min in the LALC group (P<0.001). Postoperative exhaust time in the TLLC group was (2.6±0.5) days, which was significantly shorter than (3.3±0.8) days in the LALC group (P<0.001). The incision length in the TLLC group was (4.2±2.2) cm, significantly shorter than (7.0±2.5) cm in the LALC group (P<0.001). The length of the resected bowel was (21.0±7.3) cm in the TLLC group, which was significantly longer than (17.5±5.4) cm in the LALC group (P=0.037). The length of hospital stay in the TLLC group was (6.2±1.9) days, which was significantly shorter than (7.9±1.5) days in the LALC group (P<0.001). The incidences of postoperative complications in the TLLC group and LALC group were 0 and 4.9% (3/61), respectively, without statistically significant (P=0.553). No anastomotic complications occurred in both groups. During the follow-up period, neither group of patients was hospitalized again, and no tumor metastasis or recurrence occurred. Conclusions: It is safe and feasible to apply the TLLC with overlapped delta-shaped anastomosis in patients with left colon cancer. It has better short-term effects such as shorter incisions, faster recovery, and shorter postoperative hospital stays, and is worthy of further promotion.

Anastomotic recurrence after laparoscopic distal gastrectomy with delta-shaped anastomosis†:†report of a case.

Delta-shaped anastomosis is nowadays an increasingly performed reconstruction method in laparoscopic distal gastrectomy for early gastric cancer. To date, anastomotic recurrence at the delta-shaped anastomotic site has not been reported. Surgery for this disease is more complicated than anastomotic recurrence at the site of conventional Billroth-I anastomosis. A 68-year-old female was referred to our institute with early gastric cancer on the posterior wall of the antrum. She underwent laparoscopic distal gastrectomy with delta-shaped Billroth-I anastomosis. Follow-up gastrofiberscopy 16 months after the operation revealed suspected anastomotic recurrence, and gastric biopsy revealed signet-ring cell carcinoma. Open total gastrectomy with reconstruction with the Roux-en-Y method was performed. At the distal part of the previous anastomosis, an adequate length of the duodenum was dissected from the pancreas. Then, the duodenum was transected 3 cm distal to the anastomosis using a linear stapler. The patient recovered well and was discharged on postoperative day 14. The patient is alive without re-recurrence 3 years postoperatively. We successfully treated a patient with anastomotic recurrence of gastric cancer after delta-shaped anastomosis. Adequate resection of the duodenal stump was performed without any residual tumor or injury to the pancreas. J. Med. Invest. 67 : 211-213, February, 2020.

Delta-shaped anastomosis vs circular stapler anastomosis after laparoscopic distal gastrectomy with Billroth I reconstruction: A randomized controlled trial.

INTRODUCTION: The aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with Billroth I reconstruction. METHODS: This is a single-center randomized controlled study. Eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage I tumor. Patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. The primary endpoint is the number of analgesics used during three days after surgery. We compared the surgical outcomes of the two groups. Postoperative quality of life was evaluated using the Postgastrectomy Syndrome Assessment Scale-45. This trial was registered at the UMIN Clinical Trials Registry as UMIN000025160. RESULTS: Between December 2016 and September 2018, 39 patients (delta-shaped anastomosis 18, circular stapler anastomosis 21) were enrolled. There was no difference in the number of analgesics used during three days after surgery (median nine: delta-shaped anastomosis vs nine: circular stapler anastomosis, P = .91). There was no difference in the overall proportion with in-hospital grade II-IIIB surgical complications (11%: delta-shaped anastomosis, 14%: circular stapler anastomosis). There was no operation-related death in either arm. Regarding postoperative quality of life evaluated one month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. CONCLUSION: We did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. Since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to laparoscopic distal gastrectomy with Billroth I reconstruction.

Intra-corporeal delta-shaped anastomosis in laparoscopic right hemicolectomy for right colon cancer: a safe and effective technique.

BACKGROUND AND OBJECTIVE: Intra-corporeal delta-shaped anastomosis (IDA) is an important development in laparoscopic digestive-tract reconstruction. We applied it in laparoscopic right hemicolectomy for right colon cancer and compared the short-term outcomes between the patients treated with IDA and conventional extracorporeal anastomosis (EA). METHODS: Between 1 January 2016 and 1 October 2017, 36 and 50 patients who underwent IDA and EA, respectively, were included. Data on clinicopathological characteristics, surgical outcomes, post-operative recovery and complications were collected and compared between the two groups. RESULTS: Surgical outcomes and clinicopathological characteristics were similar between the two groups except the length of incision, which was significantly shorter in the IDA group than in the EA group (4.6 ± 0.6 vs 5.6 ± 0.7 cm, P < 0.001). The time to ground activities, fluid diet intake and post-operative hospitalization did not differ between the groups; however, the time to first flatus was significantly shorter in the IDA group than in the EA group (2.8 ± 0.5 vs 3.2 ± 0.8 days, P = 0.004). The post-operative visual analogue scale for pain was lower in the IDA group than in the EA group on post-operative Day 1 (4.0 ± 0.7 vs 4.5 ± 1.0, P = 0.002) and post-operative Day 3 (2.7 ± 0.6 vs 3.4 ± 0.6, P < 0.001). The surgical complication rates were 8.3 and 16.0% in the IDA and EA groups (P = 0.470), respectively. No complications such as anastomotic bleeding, stenosis and leakage occurred in any patient. CONCLUSIONS: IDA is safe and feasible and shows more satisfactory short-term outcomes than EA.