• Journal of Gastric Cancer
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• v.12 no.2
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• pp.120-125
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• 2012

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

• Journal of Gastric Cancer
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• v.15 no.1
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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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• v.13 no.1
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• pp.34-43
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• 2013

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

• Journal of Gastric Cancer
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• v.22 no.2
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• pp.83-93
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• 2022

Background: To analyze the short- and long-term clinical outcomes of 2 reconstruction methods after distal gastrectomy for gastric cancer. Methods: Three keywords, "gastric neoplasm," "distal gastrectomy," and "reconstruction," were used to search PubMed. We selected only randomized controlled trial that compared the anastomosis methods. A total of 11 papers and 8 studies were included in this meta-analysis. All statistical analyses were performed using the R software. Results: Among short-term clinical outcomes, a shorter operation time, reduced morbidity, and shorter hospital stay were found for Billroth type I (B-I) than for Roux-en-Y (RNY) reconstruction in the meta-analysis (P<0.001, P=0.048, P<0.001, respectively). When comparing Billroth type II (B-II) to RNY, the operation time was shorter for B-II than for RNY (P<0.019), but there were no differences in morbidity or length of hospital stay (P=0.500, P=0.259, respectively).Regarding long-term clinical outcomes related to reflux, there were significantly fewer incidents of reflux esophagitis, reflux gastritis, and bile reflux (P=0.035, P<0.001, P=0.019, respectively) for RNY than for B-I in the meta-analysis, but there was no difference between the 2 methods in residual food (P=0.545). When comparing B-II to RNY, there were significantly fewer incidents of reflux gastritis (P<0.001) for RNY than for B-II, but the amount of residual food and patient weight gain showed no difference. Conclusion: B-I had the most favorable short-term outcomes, but RNY was more advantageous for long-term outcomes than for other methods. Surgeons should be aware of the advantages and disadvantages of each type of anastomosis and select the appropriate method.

• Journal of Gastric Cancer
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• v.7 no.2
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• pp.88-96
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• 2007

Purpose: The only curative treatment for gastric carcinoma is surgery and it is still under debate which reconstruction method is better after performing gastrectomy for gastric carcinoma. The typical reconstruction methods after distal gastrectomy are Billroth I, Billroth II and Roux-en Y reconstruction. Yet it is difficult to compare these methods and not so much is known about which reconstruction is better in terms of the physiologic and nutritional function. With this background, we compared two reconstruction methods after distal gastrectomy (Billroth I versus Roux-en Y reconstruction) in terms of the long term physiologic function and nutritional status to create a reference for selecting reconstruction methods after distal gastrectomy. Materials and Methods: Between 1999 and 2002, 663 patients who underwent distal gastrectomy for early gastric carcinoma filled out questionnaires every six months after operation, and these questionnaires evaluated the physiologic function. To evaluate their nutritional status, blood tests were performed every six months to check their albumin, protein and hemoglobin levels, and we checked the body weight every 6 months as well. Results: The total score of the 15 questions on the questionnaire concerned with the physiologic function showed no difference between the two groups at every evaluation time, and both groups showed very low total scores, indicating tolerable physiologic function after operation. When comparing each question between two the groups, only symptoms of regurgitation and food passage showed a difference between the two groups, showing that the Roux-en Y group had better function in terms of these two symptoms. The Billroth I group showed a better nutrition status, indicating that the level of albumin, protein and hemoglobin were higher in the Billroth I group, with statistical significance. Body weight loss was severe in the Roux-en Y group. Conclusion: The physiologic function is slightly better in the Roux-en Y group in terms of some symptoms such as regurgitation and food passage. However, the nutritional status is better in the Billroth I group. In conclusion, because we cannot definitely ascertain which reconstruction is better when we consider both the physiologic and nutritional functions, it is reasonable that surgeon should choose reconstruction methods according to their experience and preference.

• Journal of Gastric Cancer
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• v.6 no.2
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• pp.103-108
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• 2006

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=0.0019). 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.

• Journal of Gastric Cancer
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• v.11 no.4
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• pp.212-218
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• 2011

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.

• Journal of Gastric Cancer
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• v.4 no.4
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• pp.225-229
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• 2004

Purpose: Some patients develop gastroesophageal reflux disease (GERD) after a gastrectomy for stomach cancer. Therefore, we conducted this research to gain an understanding of esophageal acidity and motility change. Materials and Methods: From July 2002 to March 2004, the cases of 15 randomized patients with stomach cancer who underwent a radical subtotal gastrectomy (RSG) with Billroth I(B-I) reconstruction (n=12) or a radical total gastrectomy (RTG) with Roux-en-Y (R-Y) gastroenterostomy (n=3) were analyzed. We investigated the clinical values of the ambulatory 24-hour pH monitoring and esophageal manometry in these patients, just before discharge from the hospital after an operation. Results: GERD was present in three patients ($20\%$). Compared with two reconstructive procedures, 3 of the 12 patients in the RSG with B-I group had GERD; however, none of RTG with R-Y group had GERD. Compared with pathologic stage, 2 of 9 patients in stage I, 1 of 2 patients in stage II, none of 3 patients in stage III, and none of 1 patient in stage IV had GERD. Esophageal manometry was performed in 10 patients. Nonspecific esophageal motility disorder (NEMD) was present in 7 patients. Conclusion: Some patients had GERD as a complication following a gastrectomy for stomach cancer. We suspect that the postoperative esophageal symptom is due to not only bile reflux but also gastroesophageal acid reflux. Therefore, careful observation is recommended for the detection of GERD.

• Journal of Gastric Cancer
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• v.19 no.1
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• pp.111-120
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• 2019

Background: Billroth I anastomosis is one of the most common reconstruction methods after distal gastrectomy for gastric cancer. Intracorporeal Billroth I (ICBI) anastomosis and extracorporeal Billroth I (ECBI) anastomosis are widely used in laparoscopic surgery. Here we compared ICBI and ECBI outcomes at a major gastric cancer center. Methods: We retrospectively analyzed data from 2,284 gastric cancer patients who underwent laparoscopic distal gastrectomy between 2009 and 2017. We divided the subjects into ECBI (n=1,681) and ICBI (n=603) groups, compared the patients' clinical characteristics and surgical and short-term outcomes, and performed risk factor analyses of postoperative complication development. Results: The ICBI group experienced shorter operation times, less blood loss, and shorter hospital stays than the ECBI group. There were no clinically significant intergroup differences in diet initiation. Changes in white blood cell counts and C-reactive protein levels were similar between groups. Grade II-IV surgical complication rates were 2.7% and 4.0% in the ECBI and ICBI groups, respectively, with no significant intergroup differences. Male sex and a body mass index (BMI) ${\geq}30$ were independent risk factors for surgical complication development. In the ECBI group, patients with a BMI ${\geq}30$ experienced a significantly higher surgical complication rate than those with a lower BMI, while no such difference was observed in the ICBI group. Conclusion: The surgical safety of ICBI was similar to that of ECBI. Although the chosen anastomotic technique was not a risk factor for surgical complications, ECBI was more vulnerable to surgical complications than ICBI in patients with a high BMI (${\geq}30$).

• Journal of Gastric Cancer
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• v.17 no.4
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• pp.354-362
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• 2017

Purpose: Laparoscopic gastrectomy is accepted as a standard treatment for patients with early gastric cancer in Korea, Japan, and China. However, duodenal stump leakage remains a fatal complication after gastrectomy. We conducted a prospective phase II study to evaluate the safety of the new technique of laparoscopic reinforcement suture (LARS) on the duodenal stump. Materials and Methods: The estimated number of patients required for this study was 100 for a period of 18 months. Inclusion criteria were histologically proven gastric adenocarcinoma treated with laparoscopic distal or total gastrectomy and Billroth II or Roux-en-Y reconstruction. The primary endpoint was the incidence of duodenal stump leakage within the first 30 postoperative days. The secondary endpoints were early postoperative outcomes until discharge. Results: One hundred patients were enrolled between February 2016 and March 2017. The study groups consisted of 65 male and 35 female patients with a mean age (years) of 62.3. Of these, 63 (63%) patients had comorbidities. The mean number of retrieved lymph nodes was 38. The mean operation time was 145 minutes including 7.8 minutes of mean LARS time. There was no occurrence of duodenal stump leakage. Thirteen complications occurred, with one case of reoperation for splenic artery rupture and one case of mortality. Conclusions: Based on the results of this prospective phase II study, LARS can be safely performed in a short operation period without development of duodenal stump leakage. A future randomized prospective controlled trial is required to confirm the surgical benefit of LARS compared to non-LARS.