• Journal of Gastric Cancer
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• 제11권4호
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• pp.219-224
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• 2011

Purpose: The Roux en Y method has rarely been performed due to longer operation time and high risk of complication, despite several merits including prevention of bile reflux. We conducted a retrospective review of the result of Roux en Y reconstruction using two circular staplers after subtotal gastrectomy. Materials and Methods: From December 2008 to May 2009, a total of 26 patients underwent Roux en Y reconstruction using two circular staplers after subtotal gastrectomy, and seventy-two patients underwent Billroth-I reconstruction. Roux en Y anastomosis was performed using two circular staplers without hand sewing anastomosis. We compared clinicopathologic features and surgical outcomes between the two groups. All patients underwent gastrofiberscopy between six and twelve months after surgery to compare the bile reflux. Results: No significant differences in clinicopathologic findings were observed between the two groups, except for the rate of minimal invasive surgery (P=0.004) and cancer stage (P=0.002). No differences in the rate of morbidity (P=0.353) and admission duration (P=0.391) were observed between the two groups. Gastrofiberscopic findings showed a significant reduction of bile reflux in the remnant stomach in the Roux en Y group (P=0.019). Conclusions: When compared with Billroth-I reconstruction, Roux en Y reconstruction using the double stapler technique was found to reduce bile reflux in the remnant stomach without increasing postoperative morbidity. Based on these results, we planned to begin a randomized controlled clinical trial for comparison of Roux en Y reconstruction using this method with Billroth-I anastomosis.

• Journal of Gastric Cancer
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• 제20권3호
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• pp.337-343
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• 2020

Distal gastrectomy with Billroth I or II reconstruction may cause duodenogastroesophageal reflux (DGER), thereby resulting in digestive or respiratory symptoms. The mainstay of treatment is medication with proton pump inhibitors. However, these drugs may have limited effects in DGER. Laparoscopic fundoplication has been proven to be highly effective in treating gastroesophageal reflux disease (GERD), but it cannot be performed optimally for GERD that develops after gastrectomy. We report the case of a 72-year-old man with a history of distal gastrectomy and Billroth I anastomosis due to early gastric cancer. GERD due to bile reflux occurred after surgery and was refractory to medical therapy. The patient underwent Roux-en-Y conversion from Billroth I gastroduodenostomy and hiatal hernia repair with only cruroplasty. Fundoplication was not performed. His symptoms improved significantly after the surgery. Therefore, laparoscopic hiatal hernia repair and Roux-en-Y conversion can be an effective surgical procedure to treat medically refractory DGER after Billroth I gastrectomy.

• Journal of Gastric Cancer
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• 제9권4호
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• pp.215-222
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• 2009

목적: 원위부 위절제술 후 재건술의 하나인 Billroth II 위공장문합술은 오랫동안 사용되어온 방법이나 역류성 위염의 빈도가 높다는 것이 문제점 중의 하나이다. 이를 보완하기 위한 여러 시도가 있었으나 그 중 잔위의 크기에 따라 Roux-en-Y 위공장문합술, Braun 공장문합술 및 Billroth II 위공장문합술을 달리 시행한 후 그 적용의 적합성을 알아보고자 하였다. 대상 및 방법: 2003년 9월부터 2007년 4월까지 하부 및 중위 위선암으로 단일 술자에 의해 원위부 위절제를 받은 후 잔위의 크기가 10% 이하일 때 Roux-en-Y 위공장문합술 (14명)을, 잔위가 10~20%일 때 Braun 공장문합술(17명)을, 잔위가 20~40%일 때 Billroth I이 부적합하다고 판단된 경우 - Billroth II 위공장문합술(14명)을 시행 후, 각각의 치료성적을 분석하였다. 분석 방법은 전화 설문과 의무기록을 조사하여 환자의 증상 및 내시경 소견을 평가하였고 술 후 영양 상태를 평가하기 위하여 혈중알부민, 혈색소농도 및 체중의 변화를 측정하였다. 결과: 수술 사망률 0%, 수술 합병률 8.9% (4/45)로 모든 수술은 안전하게 시행되었다. 내시경 소견에서 역류성 위염은 Roux-en-Y군, Braun군 및 Billroth II군에서 각각 7.63%, 18.65%, 40.0%에서 보였다(P=0.13). 가벼운 역류성 식도염이 Roux-Y군과 Braun군에서 각각 1명씩 있었다. 내시경적 위저류는 Roux-en-Y군에서 2예가 보였으며 이 중 1예는 역류성식도염의 원인이 되었다. Roux-en-Y군과 Braun군이 Billroth II 군보다 식사량의 감소가 적었으며(각각 7.1%, 0.0%, 28.7%, P=0.036), 식후 불편감(각각 14.3%, 23.5%, 57.1%, P=0.035)과 역류 증상(각각 0.0%, 11.8%, 42.9%, P=0.009)을 적게 호소하였다. 결론: 작은 잔위를 가지는 환자에서 시행된 Roux-en-Y 위공장문합술과 Braun 공장문합술은 역류증상의 방지와 위절제 후 불편감을 줄이는데 효과적이라고 생각하며, 10% 미만의 잔위에서는 Roux-en-Y를, 그 외의 경우에는 Braun 문합을 확대적용을 고려하는 것이 좋겠다.

• Journal of Gastric Cancer
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• 제14권4호
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• pp.229-237
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• 2014

Purpose: Laparoscopic distal gastrectomy (LDG) is a well-established procedure for the treatment of early gastric cancer. Several reconstruction methods can be adopted after LDG according to tumor characteristics and surgeon preference. This study aimed to compare the remnant gastric functions after different reconstructions. Materials and Methods: In total, 221 patients who underwent LDG between March 2005 and October 2013 were reviewed retrospectively. The patients were classified into four groups based on the reconstructive procedure: Billroth I (BI) anastomosis, Billroth II (BII) with Braun anastomosis, Roux-en-Y (RY) reconstruction, or uncut RY reconstruction. Patient demographics, surgical outcomes, and postoperative endoscopic findings were reviewed and compared among groups. Results: Endoscopic evaluations at $11.8{\pm}3.8$ months postoperatively showed less frequent gastritis and bile reflux in the remnant stomach in the RY group compared to the BI and BII groups. There was no significant difference in the gastric residue among the BI, BII, and RY groups. The incidence of gastritis and bile reflux in the uncut RY group was similar to that in the RY group, while residual gastric content in the uncut RY group was significantly smaller and less frequently observed than that in the RY group (5.8% versus 35.3%, P=0.010). Conclusions: RY and uncut RY reconstructions are equally superior to BI and BII with Braun anastomoses in terms of gastritis and bile reflux in the remnant stomach. Furthermore, uncut RY reconstruction showed improved stasis compared to conventional RY gastrojejunostomy. Uncut RY reconstruction can be a favorable reconstructive procedure after LDG.

• Journal of Gastric Cancer
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• 제15권2호
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• pp.105-112
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• 2015

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 $214.5{\pm}36.2$ minutes for uDelta and $240.8{\pm}65.9$ minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance ($26.1{\pm}8.3$ minutes vs. $38.0{\pm}9.1$ 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 $8.2{\pm}1.9$ days in the uDelta group and $7.2{\pm}0.8$ 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.

• Journal of Gastric Cancer
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• 제17권3호
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• pp.255-266
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• 2017

Purpose: Although Roux-en-Y (R-Y) reconstruction after distal gastrectomy has several advantages, such as prevention of bile reflux into the remnant stomach, it is rarely used because of the technical difficulty. This prospective randomized clinical trial aimed to show the efficacy of a novel method of R-Y reconstruction involving the use of 2 circular staplers by comparing this novel method to Billroth-I (B-I) reconstruction. Materials and Methods: A total of 118 patients were randomly allocated into the R-Y (59 patients) and B-I reconstruction (59 patients) groups. R-Y anastomosis was performed using two circular staplers and no hand sewing. The primary end-point of this clinical trial was the reflux of bile into the remnant stomach evaluated using endoscopic and histological findings at 6 months after surgery. Results: No significant differences in clinicopathological findings were observed between the 2 groups. Although anastomosis time was significantly longer for the patients of the R-Y group (P<0.001), no difference was detected between the 2 groups in terms of the total surgery duration (P=0.112). Endoscopic findings showed a significant reduction of bile reflux in the remnant stomach in the R-Y group (P<0.001), and the histological findings showed that reflux gastritis was more significant in the B-I group than in the R-Y group (P=0.026). Conclusions: The results of this randomized controlled clinical trial showed that compared with B-I reconstruction, R-Y reconstruction using circular staplers is a safe and feasible procedure. This clinical trial study was registered at www.ClinicalTrials.gov (registration No. NCT01142271).

• Journal of Gastric Cancer
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• 제19권3호
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• pp.344-354
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• 2019

Purpose: No standard technique has been established for esophagojejunal anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer owing to the technical difficulty and high complication rate of this procedure. This study was performed to compare the short-term outcomes of circular and linear stapling methods after LTG. Materials and Methods: A total of 106 patients treated between July 2010 and July 2018 were divided into 2 groups according to the following anastomosis procedures: hemi-double-stapling technique (HDST; circular stapling method; group C, n=77) or overlap method (linear stapling method; group L, n= 29). The clinicopathological features and postoperative outcomes, including complications, were analyzed. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for anastomotic complications. Results: The incidence of anastomotic complications was significantly higher in group C than in group L (28.0% vs. 6.9%, P=0.031). The incidence of anastomosis leakage did not differ between the groups (6.5% vs. 6.9%, P=1.000). However, anastomosis stricture occurred only in group C (13% vs. 0%, P=0.018). Multivariate analysis showed that the anastomosis type was significantly related to the risk of anastomotic complications (P=0.045). Conclusions: The overlap method was superior to the HDST with respect to anastomotic complications, especially anastomosis stricture.

• Journal of Gastric Cancer
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• 제15권1호
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• pp.46-52
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• 2015

Purpose: The aim of this study was to compare the short-term surgical and long-term functional outcomes of Billroth I, Billroth II, and Roux-en-Y reconstruction after laparoscopic distal gastrectomy. Materials and Methods: We retrospectively collected data from 697 patients who underwent laparoscopic distal gastrectomy for operable gastric cancer between January 2009 and December 2012. The patients were classified into three groups according to the reconstruction methods: Billroth I, Billroth II, and Roux-en-Y. The parameters evaluated included patient and tumor characteristics, operative details, and postoperative complications classified according to the Clavien-Dindo classification. Endoscopic findings of the remnant stomach were evaluated according to the residue, gastritis, bile (RGB) classification and the Los Angeles classification 1 year postoperatively. Results: Billroth I, Billroth II, and Roux-en-Y were performed in 165 (23.7%), 371 (53.2%), and 161 patients (23.1%), respectively. Operation time was significantly shorter ($173.4{\pm}44.7$ minute, P<0.001) as was time to first flatus ($2.8{\pm}0.8$ days, P=0.009), time to first soft diet was significantly faster ($4.3{\pm}1.0$ days, P<0.001), and postoperative hospital stay was significantly shorter ($7.7{\pm}4.0$ days, P=0.004) in Billroth I in comparison to the other methods. Postoperative complications higher than Clavien-Dindo grade III occurred in 61 patients (8.8%) with no statistically significant differences between groups (P=0.797). Endoscopic findings confirmed that gastric residue, gastritis, bile reflux, and reflux esophagitis were significantly lower in Roux-en-Y (P<0.001) patients. Conclusions: Roux-en-Y reconstruction after laparoscopic distal gastrectomy for middle-third gastric cancer is beneficial in terms of long-term functional outcome, whereas Billroth I reconstruction for distal-third gastric cancer has a superior short-term surgical outcome and postoperative weight change.

• Journal of Gastric Cancer
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• 제7권3호
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• pp.146-151
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• 2007

목적: Pledget은 주로 심혈관계 수술에서 매듭을 보강하는 용도로 사용되는 PTFE 재질의 섬유조각이다. 연구자들은 복강경 수술에서 복강 내 매듭짓기의 횟수를 줄임으로써 복강 내 위장관 연속 손바느질을 기술적으로 용이하게 하기 위하여 pledget을 매듭의 대용으로 이용하였다. 대상 및 방법: 본원에서 전복강경하 uncut Roux-en-Y 위공장문합술을 시행 받은 32명의 환자들을 복강 내 문합의 방법에 따라 3군으로 나누어 각 군간의 수술 결과를 비교, 분석하였다. 복강 내 문합에서 기본적으로는 선형문합기를 사용하였지만 A군에서는 공장공장문합부와 위공장문합부의 문합기가 들어간 구멍을 pledget을 이용한 손바느질로 막았고, B군에서는 공장공장문합부의 문합기가 들어간 구멍을 기존의 손바느질로 막았으며, C군에서는 문합기가 들어간 구멍을 모두 선형문합기로 막았다. 결과: A군에서의 손바느질의 양이 B군에 비해 훨씬 더 많았음에도 불구하고 문합시간은 두 군 사이에 별다른 차이가 없었으며 C군의 문합시간보다는 A군의 문합시간이 더 길었다. 사용한 선형문합기 카트리지의 수는 세 군중 A군에서 가장 작았다. B군에서는 복강 내 손바느질 도중에 봉합사가 끊어지는 예가 2예 있었으나 A군에서는 그러한 예가 한 예에서도 발생하지 않았다. 결론: Pledget은 복강 내 위장관 연속 손바느질에서 매듭의 수를 줄여 문합시간을 단축하는 데 유용하였다.

• Journal of Gastric Cancer
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• 제22권3호
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• pp.220-234
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• 2022

Purpose: The incidence of adenocarcinoma of the esophagogastric junction (AEG) has increased in recent years, and the optimal surgical strategy for AEG remains highly controversial. We aimed to evaluate the safety and efficacy of proximal gastrectomy with double-tract reconstruction (PG-DT) for the treatment of patients with AEG. Materials and Methods: We retrospectively analyzed patients with Siewert type II/III AEG between January 2013 and July 2018. Clinicopathological characteristics, survival, surgical outcomes, quality of life (QOL), and nutritional status were compared between the PG-DT and total gastrectomy with Roux-en-Y anastomosis (TG-RY) groups. Results: After propensity score matching, 33 patients in each group were analyzed. There were no statistical differences between the 2 groups in terms of disease-free survival and overall survival. The surgical option was not an independent prognostic factor based on the multivariate analysis. In addition, no differences were found in terms of surgical complications. There were no significant differences in QOL assessed by the Visick grade, Gastrointestinal Symptom Rating Scale, or endoscopic findings. Furthermore, the long-term nutritional advantage of the PG-DT group was significantly greater than that of the TG-RY group. Conclusions: PG-DT is a safe and effective procedure for patients with local Siewert type II/III AEG, regardless of the TNM stage.