Humans ; Bile Reflux/complications* ; Cross-Sectional Studies ; Risk Factors ; Gastric Mucosa

PURPOSE: Although linear-shaped gastroduodenostomy (LSGD) was reported to be a feasible and reliable method of Billroth I anastomosis in patients undergoing totally laparoscopic distal gastrectomy (TLDG), the feasibility of LSGD for patients undergoing totally robotic distal gastrectomy (TRDG) has not been determined. This study compared the feasibility of LSGD in patients undergoing TRDG and TLDG.MATERIALS AND METHODS: ALL C: onsecutive patients who underwent LSGD after distal gastrectomy for gastric cancer between January 2009 and December 2017 were analyzed retrospectively. Propensity score matching (PSM) analysis was performed to reduce the selection bias between TRDG and TLDG. Short-term outcomes, functional outcomes, learning curve, and risk factors for postoperative complications were analyzed.RESULTS: This analysis included 414 patients, of whom 275 underwent laparoscopy and 139 underwent robotic surgery. PSM analysis showed that operation time was significantly longer (163.5 vs. 132.1 minutes, P<0.001) and postoperative hospital stay significantly shorter (6.2 vs. 7.5 days, P<0.003) in patients who underwent TRDG than in patients who underwent TLDG. Operation time was the independent risk factor for LSGD after intracorporeal gastroduodenostomy. Cumulative sum analysis showed no definitive turning point in the TRDG learning curve. Long-term endoscopic findings revealed similar results in the two groups, but bile reflux at 5 years showed significantly better improvement in the TLDG group than in the TRDG group (P=0.016).CONCLUSIONS: LSGD is feasible in TRDG, with short-term and long-term outcomes comparable to that in TLDG. LSGD may be a good option for intracorporeal Billroth I anastomosis in patients undergoing TRDG.
Bile Reflux ; Gastrectomy ; Gastroenterostomy ; Humans ; Laparoscopy ; Learning Curve ; Length of Stay ; Methods ; Postoperative Complications ; Propensity Score ; Retrospective Studies ; Risk Factors ; Robotic Surgical Procedures ; Selection Bias ; Stomach Neoplasms

We present the case of a patient with biliary and duodenal atresia who showed false-negative hepatobiliary scintigraphy results. The patient was born at 37 weeks and 2 days of gestation. Her mother had undergone amnioreduction after detection of a double-bubble ultrasound sign in the fetal abdomen. At 2 days of age, total serum bilirubin level was elevated. On hepatobiliary scintigraphy 4 days later, the gallbladder was visualized from 30 min and it showed duodeno-gastric reflux at 240 min. After 24 h, the radiotracer was almost washed out in the hepatic parenchyma, but there was retention in the gastroduodenal junction. Because the biliary to duodenal transit was visible, biliary atresia seemed unlikely. Abdominal ultrasonography at 7 days of age showed a small dysmorphic gallbladder, but triangular cord sign was not definite. Magnetic resonance cholangiography revealed atretic gallbladder. Although cystic and common bile ducts were visible, the proximal common hepatic bile duct was not visible. The next day, serum total bilirubin levels remained elevated (17.1 mg/dl) with direct bilirubin level of 1.2 mg/dl. Kasai portoenterostomy with duodeno-duodenostomy was performed at 10 days of age. Histopathological evaluation showed a fibrous obliteration of the common bile duct, consistent with that of biliary atresia.
Abdomen ; Bile Ducts ; Biliary Atresia ; Bilirubin ; Cholangiography ; Common Bile Duct ; Duodenogastric Reflux ; Gallbladder ; Humans ; Infant, Newborn ; Jaundice, Neonatal ; Mothers ; Pregnancy ; Radionuclide Imaging ; Ultrasonography

PURPOSE: A delta-shaped anastomosis (DA) is a widely accepted technique used for a totally laparoscopic distal gastrectomy (TLDG). Several studies have suggested various modifications to overcome the drawbacks of an original DA. We present our novel technique―a T-shaped modified delta anastomosis (TDA), and we report the early outcomes with its use in a case series. METHODS: We retrospectively reviewed the medical records of 40 patients who underwent a TLDG with TDA for early gastric cancer at OOO between February 2016 and May 2017. Perioperative outcomes, postoperative complications, and operating time were analyzed, and all data were expressed as means±standard deviation. RESULTS: We observed no major complications that required immediate postoperative intervention. Other minor and non-surgical complications were delayed gastric emptying (n=1), pneumonia (n=2), atelectasis (n=3), dumping symptom (n=1), and symptomatic bile reflux (n=1). No wound infection was reported in any patient. The total operative time was 206.5±25.4 min and the estimated blood loss was 27.8±33.5 ml. The mean time required to perform the anastomosis was 20.9±6.7 min, and the mean number of cartridges used during the operation was 4.78±0.66. CONCLUSION: We conclude that a TDA following a laparoscopic distal gastrectomy was successfully developed and showed acceptable clinical outcome.
Bile Reflux ; Gastrectomy ; Gastric Emptying ; Humans ; Laparoscopy ; Medical Records ; Operative Time ; Pneumonia ; Postoperative Complications ; Pulmonary Atelectasis ; Retrospective Studies ; Stomach Neoplasms ; Wound Infection

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).
Bile ; Bile Reflux ; Gastrectomy* ; Gastric Stump ; Gastritis ; Hand ; Humans ; Methods ; Prospective Studies ; Stomach Neoplasms*

Endoscopy plays an important role in the diagnosis and treatment of postoperative complications of gastric cancer. Endoscopic intervention can avoid the second operation and has attracted wide attention. Early gastric anastomotic bleeding after gastrectomy is the most common. With the development of technology, emergency endoscopy and endoscopic hemostasis provide a new treatment approach. According to the specific circumstances, endoscopists can choose metal clamp to stop bleeding, electrocoagulation hemostasis, local injection of epinephrine or sclerotherapy agents, and spraying specific hemostatic agents. Anastomotic fistula is a serious postoperative complication. In addition to endoscopically placing the small intestine nutrition tube for early enteral nutrition support treatment, endoscopic treatment, including stent, metal clip, OTSC, and Over-stitch suture system, can be chosen to close fistula. For anastomotic obstruction or stricture, endoscopic balloon or probe expansion and stent placement can be chosen. For esophageal anastomotic intractable obstruction after gastroesophageal surgery, radial incision of obstruction by the hook knife or IT knife, a new method named ERI, is a good choice. Bile leakage caused by bile duct injury can be treated by placing the stent or nasal bile duct. In addition, endoscopic methods are widely used as follows: abdominal abscess can be treated by the direct intervention under endoscopy; adhesive ileus can be treated by placing the catheter under the guidance of endoscopy to attract pressure; alkaline reflux gastritis can be rapidly diagnosed by endoscopy; gastric outlet obstruction mainly caused by cancer recurrence can be relieved by metal stent placement and the combination of endoscopy and X-ray can increase success rate; pyloric dysfunction and spasm caused by the vagus nerve injury during proximal gastrectomy can be treated by endoscopic pyloromyotomy, a new method named G-POEM, and the short-term outcomes are significant. Endoscopic submucosal dissection (ESD) allows complete resection of residual gastric precancerous lesions, however it should be performed by the experienced endoscopists.
Anastomosis, Surgical ; adverse effects ; Bile Ducts ; injuries ; Constriction, Pathologic ; etiology ; therapy ; Digestive System Fistula ; etiology ; therapy ; Duodenogastric Reflux ; diagnostic imaging ; etiology ; Endoscopy, Gastrointestinal ; methods ; Enteral Nutrition ; instrumentation ; methods ; Female ; Gastrectomy ; adverse effects ; Gastric Outlet Obstruction ; surgery ; Gastritis ; diagnosis ; Gastrointestinal Hemorrhage ; etiology ; therapy ; Hemostasis, Endoscopic ; methods ; Hemostatics ; administration & dosage ; therapeutic use ; Humans ; Male ; Neoplasm Recurrence, Local ; surgery ; Postoperative Complications ; diagnosis ; therapy ; Precancerous Conditions ; surgery ; Pylorus ; innervation ; physiopathology ; surgery ; Stents ; Stomach Neoplasms ; complications ; surgery ; Treatment Outcome ; Vagus Nerve Injuries ; etiology ; surgery

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.
Asian Continental Ancestry Group ; Bile Reflux ; Dilatation ; Dumping Syndrome ; Gallstones ; Gastrectomy* ; Gastroparesis ; Humans ; Incidence ; Lymph Node Excision ; Nutritional Status ; Pylorus ; Quality of Life ; Stents ; Stomach ; Stomach Neoplasms* ; Vagus Nerve

Laparoscopic completion total gastrectomy following pancreaticoduodenectomy (PD) has not been reported. A 73-year-old male who underwent PD 25 years ago for distal common bile duct cancer visited a surgical department for remnant gastric cancer. A previous reconstruction was performed with pancreaticojejunostomy (PJ), gastrojejunostomy and Braun anastomosis, i.e., jejunojejunostomy (JJ), between the afferent and efferent jejunal limb to prevent bile reflux into the remnant stomach. Adhesiolysis was initially performed to secure the surgical view. Lymph node dissections around the splenic artery, splenic hilum, celiac axis, left gastric artery, and common hepatic artery were performed. The PJ site was well visualized and safely preserved. Esophagojejunostomy was performed with an OrVil system. Specimen retrieval, Roux-limb preparation and JJ were performed through an extended umbilicus trocar site. A final pathologic examination revealed a 5.5-cm serosa-exposed tumor (T4a) without lymph node metastasis. The patient was discharged on postoperative day 7 without any complications.
Aged ; Arteries ; Axis, Cervical Vertebra ; Bile Duct Neoplasms* ; Bile Ducts* ; Bile Reflux ; Bile* ; Common Bile Duct ; Extremities ; Gastrectomy* ; Gastric Bypass ; Gastric Stump ; Hepatic Artery ; Humans ; Laparoscopy ; Lymph Node Excision ; Lymph Nodes ; Male ; Neoplasm Metastasis ; Pancreaticoduodenectomy* ; Pancreaticojejunostomy ; Splenic Artery ; Stomach Neoplasms* ; Surgical Instruments ; Umbilicus

Roux-en-y gastric bypass (RYGB) is currently used to treat obesity and metabolic syndrome. It is however technically challenging with a steep learning curve and long operating times. Laparoscopitc mini-gastric bypass (LMGB) is another surgical method that is acclaimed to achieve similar efficacy and yet safe with acceptable complication rates. We reviewedcurrent literature on LMGB on its efficacy and safety profile. Comprehensive search of available literature using a combination of key words was performed, looking out for efficacy and safety end points. Efficacy end points include excess weight loss, change in body mass index (BMI), resolution of metabolic syndrome or T2DM remission. Safety end points include mortality and morbidity rates, short and long term complications. 18 studies were selected with a total of 9392 patients. Follow up range was from 1 year to 6 years with majority of studies achieving 57%-92% excess weight loss (%EWL) within 1 year. Remission of T2DM rates were mostly more than 84%. Several studies reported better %EWL and T2DM remission when compared to SG and RYGB. Overall mortality rate was 0.152%. Morbidity rates vary from 2.7%-12.5%. Some studies reported lower mortality and complication rates in LMGB when compared to SG and RYGB. In summary, MGB is a safe and effective metabolic-bariatric procedure in treating morbid obesity and T2DM. It should be considered an alternative to standard RYGB. Risk of bile reflux, marginal ulcer and anemia needs to be explained to the patient when counselling for such procedure.
Anemia ; Bile Reflux ; Body Mass Index ; Follow-Up Studies ; Gastric Bypass* ; Humans ; Learning Curve ; Methods ; Mortality ; Obesity ; Obesity, Morbid* ; Peptic Ulcer ; Weight Loss

PURPOSE: This study presents findings on the clinical usefulness of an overlap method that is another modification for the currently well-known intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG). METHODS: We studied 42 patients diagnosed with gastric cancer who underwent TLDG between December 2011 and March 2013. Endoscopic linear staplers were used for intracorporeal anastomosis and patients were observed with endoscopic tracking six months after surgery. We retrospectively reviewed the outcome of the operation, the clinical pathological results, and the endoscopy results. RESULTS: The mean duration of the operation for 42 patients was 228.3 +/- 42.5 minutes and the mean time to complete the anastomosis was 12.18 +/- 2.3 minutes. There were no mortalities and no cases of open conversion. Following the operation, 37 patients had stage IA, 5 in stage IB, and 3 in stage II gastric cancer. Abscesses were seen in 3 patients and 5 cases of stasis during the postoperative period. Duodenoscopy 6 months after the operation showed 11 cases of gastric stasis, 28 cases of bile reflux, and 1 new case of erosive gastritis. We did not observe contraction in any of the patients. CONCLUSION: The overlap method for intracorporeal gastroduodenostomy, using an endoscopic linear stapler, can be considered a feasible and safe technique for the treatment of stomach cancer. However, a long-term comparative study is required to sufficiently evaluate our findings.
Abscess ; Bile Reflux ; Duodenoscopy ; Endoscopy ; Gastrectomy* ; Gastritis ; Gastroparesis ; Humans ; Laparoscopy ; Mortality ; Postoperative Period ; Retrospective Studies ; Stomach Neoplasms*