Anastomosis, Surgical ; Gastrectomy/adverse effects* ; Humans ; Jejunum/surgery* ; Laparoscopy ; Retrospective Studies ; Stomach Neoplasms/surgery*

Laparoscopic techniques are more and more poplular in proximal gastrectomy. The traditional esophagogastric anastomosis may lead to severe reflux esophagitis after surgery, affecting patient's quality of life. In recent years, multiple methods of digestive tract reconstruction after laparoscopic proximal gastrectomy capable of resisting reflux have been applied to the clinic. Combining the results of the latest clinical studies and our clinical experience, we elaborate the views on digestive tract reconstruction after laparoscopic proximal gastrectomy. Esophagogastric anastomosis (posterior esophagogastric anastomosis, anterior esophagogastric anastomosis, gastric tube reconstruction, lateral esophagogastric anastomosis, Kamikawa anastomosis and modified Kamikawa anastomosis, etc.) and esophagojejunal anastomosis (interposition jejunum, interposition jejunum with pouch, and double-channel anastomosis, etc.) are mainly discussed. Of course, the anti-reflux mechanisms of different surgical procedures are not the same, the anti-reflux effects are variable, and the surgical difficulties under laparoscopy are also different. Therefore, how to choose a rational reconstruction method after proximal gastrectomy needs to be comprehensively considered based on patient's own situation and technical level of the surgeons.
Anastomosis, Surgical/methods* ; Esophagitis, Peptic/surgery* ; Gastrectomy/methods* ; Humans ; Jejunum/surgery* ; Laparoscopy ; Quality of Life ; Retrospective Studies ; Stomach Neoplasms/surgery*

With the development of instrument, equipment and surgical skills, especially the emergence of a series of high-level medical evidence, the laparoscopic techniques in the field of gastric surgery has been further expanded. Totally laparoscopic total gastrectomy (TLTG) has certain technical difficulties, and more challenges are reflected in the digestive tract reconstruction. The use of linear staplers has reduced the difficulty of digestive tract reconstruction to a certain extent and has strongly promoted the transition from laparoscopic-assisted total gastrectomy to TLTG. However, for TLTG, there are still many details that should be carefully concerned, so as to effectively avoid the surgical pitfalls and ensure the fluency and safety of the procedure. In this article, we discuss the surgical details based on our own experiences, including how to obtain surgical field exposure well, how to manage specific accidents when using linear stapler for esophagojejunostomy, how to prevent intra-abdominal hernias and Roux stasis syndrome, and how to prevent the stapled lines of the esophageal or jejunal stumps from direct contact with aorta.
Anastomosis, Surgical/methods* ; Gastrectomy/methods* ; Humans ; Jejunum/surgery* ; Laparoscopy/methods* ; Stomach Neoplasms/surgery*

There still remain some problemsin digestive tract reconstruction after robotic radical gastrectomy for gastric cancer at present, such as great surgical difficulties and high technical requirements. Based on the surgical experience of the Gastric Surgery Department of Union Hospital, Fujian Medical University and the literatures at home and abroad, relevant issues are discussed in terms of robotic radical distal gastrectomy (Billroth I, Billroth II, and Roux-en-Y gastrojejunostomy), proximal gastrectomy (double-channel and double-muscle flap anastomosis), and total gastrectomy (Roux-en-Y anastomosis, functional end-to-end anastomosis, FEEA, π-anastomosis, Overlap anastomosis, and modified Overlap anastomosis with delayed amputation of jejunum, i.e. later-cut Overlap). This article mainly includes (1) The principles of digestive tract reconstruction after robotic radical gastrectomy for gastric cancer. (2) Digestive tract reconstruction after robotic radical distal gastrectomy: Aiming at the weakness of traditional triangular anastomosis, we introduce the improvement of the technical difficulty, namely "modified triangular anastomosis", and point out that because Billroth II anastomosis is a common anastomosis method in China at present, manual suture under robot is more convenient and safe, and can effectively avoid anastomotic stenosis. (3) Digestive tract reconstruction after robotic proximal gastrectomy: It mainly includes double channel anastomosis and double muscle flap anastomosis, but these reconstruction methods are relatively complicated, and robotic surgery has not been widely carried out at present. (4) Digestive tract reconstruction after robotic total gastrectomy: The most classic one is Roux-en-Y anastomosis, mainly using circular stapler for end-to-side esophagojejunal anastomosis and linear stapler for side-to-side esophagojejunal anastomosis, for which we discuss the solutions to the existing technical difficulties. With the continuous innovation of robotic surgical system and anastomosis instruments, and with the gradual improvement of anastomosis technology, it is believed that digestive tract reconstruction after robotic radical gastrectomy for gastric cancer will have a good application prospect in gastric cancer surgery.
Anastomosis, Roux-en-Y/methods* ; Gastrectomy/methods* ; Humans ; Jejunum/surgery* ; Laparoscopy ; Robotic Surgical Procedures ; Robotics ; Stomach Neoplasms/surgery*

OBJECTIVE: To explore the safety, feasibility and short-term efficacy of intracavitary uncut Roux-en-Y (URY) anastomosis in digestive tract reconstruction following laparoscopic total gastrectomy (LTG). METHODS: From November 2015 to January 2018, 67 gastric cancer patients underwent intracavitary URY following LTG to reconstruct the digestive tract at Oncological Surgery Department of Fujian Provincial Hospital. There were 41 males and 26 females with age of 50 to 81 (61.9±7.4) years and body mass index (BMI) of (23.4±3.2) kg/m². Among 67 patients, 19 were gastric cardia carcinomas, 33 were gastric body carcinomas, and 15 were gastric fundus carcinomas; tumor size was (3.4±2.3) cm; 22 were Borrmann type I, 15 were type II, 21 were type III, and 19 were type IV; 29 were highly or moderately differentiated adenocarcinoma, 23 were lowly differentiated adenocarcinoma, and 15 were signet-ring cell carcinoma. After conventional laparoscopic D2 radical gastrectomy, the duodenum was closed and dissociated at 2 cm below the pyloric ring using the Echelon-flex endoscopic articulated linear Endo-GIA stapler, and the esophagus was dissociated above the esophagogastric junction (EGJ).URY and digestive tract reconstruction were performed under the direct vision of laparoscope: (1) Side-to-side esophagojejunostomy: An incision of 0.5 cm was made in the left lower edge of the esophageal closed end; jejunum about 25 cm distal away from the Treitz ligament was elevated to the lower end of esophagus; another incision of 0.5 cm was made in the contralateral of mesenteric side; both arms of the linear Endo-GIA stapler were inserted into the windows opened through esophagus and jejunum respectively to complete side-to-side anastomosis. The common opening of esophagus and jejunum was closed to complete esophagojejunostomy, forming the chyme outflow tract. (2) Side-to-side Braun jejunojejunostomy: Incisions of 0.5 cm were made in the proximal jejunum about 10 cm away from the esophagojejunal anastomosis and 35-40 cm away from the contralateral of mesenteric side of distal jejunum respectively for proximal-distal side-to-side jejunojejunostomy. The common opening was closed to form the biliopancreatic duodenal juice outflow tract. (3) Closure of the input loop jejunum in the esophagojejunal anastomosis: The input loop jejunum 2-3 cm away from the esophagojejunal anastomosis was closed using the non-blade linear stapler (ATS45NK), and the biliopancreatic duodenal juice reflux was blocked. Clinical data of these patients were collected for retrospective case series study. Surgical and digestive tract functional recovery, perioperative complications, as well as postoperative nutritional status were observed. Moreover, related indexes, such as anastomosis function and tumor recurrence were evaluated through endoscopic and imaging examinations during postoperative follows-up. RESULTS: All the 67 patients completed the surgery successfully. The mean operative time was (259.4±38.5) minutes, digestive tract reconstruction time was (38.2±13.2) minutes, intraoperative blood loss was (73.4±38.4) ml, and number of harvested lymph node was 36.2±14.2. The mean distance from upper resection margin to upper tumor edge was (3.3±1.2) cm, distance from upper resection margin to dentate line was (1.2±0.7) cm, and 1 case had positive upper incisal margin, which became negative after the second resection. Moreover, the average length of the auxiliary incision was (3.2±0.4) cm. The mean postoperative intestinal exhaust time was (52.8±26.4) hours, time to liquid diet was (64.8±28.8) hours, and postoperative hospital stay was (8.4±2.5) days. The morbidity of postoperative complication was 10.4%(7/67). Among these 7 cases, 4 cases were grade IIIa of Clavien-Dindo classification, including 2 with esophagojejunal anastomosis leakage, 1 with duodenal stump leakage, and 1 with abdominal infection, and all these patients were recovered after conservative treatment. All the 67 patients were followed up. The mean nutrition index 12 months after surgery was 53.4±4.2, diameter of esophagojejunal anastomosis was (3.9±0.6) cm, the incidence of Roux-en-Y stasis syndrome was 3.0% (2/67), and the incidence of reflux esophagitis was 4.5% (3/67). No patient had recanalization of the closed input loop of esophagojejunal anastomosis, anastomotic stenosis, obstruction, or tumor recurrence at anastomosis. CONCLUSION Intracavitary URY anastomosis following LTG for digestive tract reconstruction is safe and feasible, leading to fast postoperative recovery of digestive tract function and favorable short-term efficacy.
Anastomosis, Roux-en-Y ; methods ; Anastomosis, Surgical ; Female ; Gastrectomy ; methods ; Humans ; Jejunum ; Laparoscopy ; Male ; Retrospective Studies ; Stomach Neoplasms ; surgery

PURPOSE: To report our initial experience with laparoscopic mini-gastric bypass (LMGB) in Korean obese patients.MATERIALS AND METHODS: From July 2016 to February 2018, 14 male patients underwent LMGB for morbid obesity at a single institution. Five trocars were placed in a U-shape formation and 1 trocar was placed at the epigastrium as a liver retractor; a window was created between the vagal nerve and lesser curvature at the gastric angle for entering the lesser sac; a narrow gastric tube (~100–120 ml volume) was made; a linear-stapled gastrojejunostomy was created after bypassing the jejunum 200 cm from the Treitz' ligament; and the Petersen defect was closed to prevent internal hernia. Patient demographics, operative time, estimated blood loss, postoperative hospital stay, complications, weight loss, and resolution of comorbidities were evaluated during 1 year of follow-up.RESULTS: All procedures were successful by laparoscopy. The average age was 29 (19–49) years; weight, 164.9 (127-250) kg; and body mass index, 51.0 (42.4–81.6) kg/m². In 1 case, nephrectomy was simultaneously performed for early renal cell carcinoma. The mean operative time was 148.8 (120-175) min. The mean postoperative hospital stay was 1.9 (1–4) days. The percentage excess weight loss at 1, 3, 6, 9, and 12 months was 16.6%, 31.0%, 41.4%, 45.4%, and 50.4%, respectively. The resolution rate of type 2 diabetes mellitus, hypertension, and dyslipidemia was 75%, 40%, and 66.7%, respectively. There was no major complication including mortality during the follow-up.CONCLUSION: LMGB is a technically simple, safe, and effective procedure in Korean obese patients.
Bariatric Surgery ; Body Mass Index ; Carcinoma, Renal Cell ; Comorbidity ; Demography ; Diabetes Mellitus, Type 2 ; Dyslipidemias ; Follow-Up Studies ; Gastric Bypass ; Hernia ; Humans ; Hypertension ; Jejunum ; Laparoscopy ; Length of Stay ; Ligaments ; Liver ; Male ; Mortality ; Nephrectomy ; Obesity, Morbid ; Operative Time ; Peritoneal Cavity ; Postoperative Hemorrhage ; Surgical Instruments ; Weight Loss

OBJECTIVETo explore the feasibility, safety, and preliminary technical experience of single incision plus one port laparoscopic total gastrectomy combined with π-shaped esophagojejunal anastomosis (SILT-π) in the surgical treatment of gastric cancer.

METHODSClinical data of 5 gastric cancer patients undergoing SILT-π operation at the Department of General Surgery, The Second Affiliated Hospital of the Army Medical University from August to October 2017 were retrospectively analyzed. A 2.5-3.0 cm incision around the umbilicus was made for placing the gloveport as the passage for the lens, and the instruments of the surgeon and the assistant. Another operative port was placed in the left upper quadrant with a 12-mm Trocar for the passage of the energy device, the endoscopic cutting closure, as well as the postoperative drainage tube. A D2 lymph node (LNs) dissection was regularly conducted. After the abdominal esophagus was routinely mobilized, a side-to-side esophagus-jejunum anastomosis was made through a gastric pre-pulling esophagojejunal π-shaped anastomosis. The transection was then performed with a ligation on the cardia (or esophagus above the upper margin of the tumor) using a sterilized hemp rope in order to better expose the abdominal esophagus. Throughout the course of reconstruction, the ligature rope was held by the assistant to hold down the esophagus to allow easier esophagojejunal anastomosis. A hole was then made on the posterior wall of the esophagus, between 2 cm and 3 cm above the ligature rope, and another hole was made at the anti-mesenteric border of the jejunum 40 cm distal to the Treitz ligament. A side-to-side esophagojejunal π-shaped anastomosis was performed through two holes. An entry hole was formed after the anastomosis. After checking the anastomosis, this entry hole was closed through an intestinal mesenteric hole pre-made on its opposite side. The resected esophagus and stomach, together with the afferent loop jejunum, were simultaneously transected above the level of the entry hole by a stapler from the Trocar of the left upper abdominal quadrant. After the gloveport was closed, a side-to-side jejunojejunostomy anastomosis applied with another two staples was performed between the afferent loop stump and the roux limb 30 cm below the esophagojejunal anastomosis.

RESULTSThese five patients were all male, and aged (56.8±8.2) years with preoperative clinical stage cT2-4N0-2M0. All the 5 patients underwent SILT-π operation successfully. The average length of surgical incision was (2.9±0.2) cm. The average operation time was (396.0±36.1) minutes. The intraoperative blood loss was (140.0±66.7) ml. Postoperative pathology showed proximal and distal margins were (2.6±1.1) cm and (8.7±2.5) cm apart respectively, and the average number of retrieved lymph node was 25.8±7.2. Perioperative management was based on enhanced recovery following surgical (ERAS) principles. The average time to the first flatus was (2.6±0.5) days, and the average time to defecation was (3.6±0.5) days. The pain score on postoperative day 1 was 1-2, and the average postoperative hospital stay was (7.0±0.7) days. No perioperative complications occurred.

CONCLUSIONSSILT-π procedure is safe and feasible for patients with gastric cancer, and has positive short-term outcomes, satisfactory cosmetic abdominal incision, light postoperative abdominal pain and rapid postoperative recovery. Preliminary observations show that SILT-π procedure has good potential for clinical application in future.

Aged ; Anastomosis, Surgical ; Esophagus ; surgery ; Gastrectomy ; methods ; Humans ; Jejunum ; surgery ; Laparoscopy ; Male ; Middle Aged ; Retrospective Studies ; Stomach Neoplasms ; surgery

The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion.
Adolescent ; Chronic Disease ; Esophageal and Gastric Varices/complications ; Esophageal and Gastric Varices/diagnostic imaging ; Esophageal and Gastric Varices/therapy ; Female ; Gastrointestinal Hemorrhage/complications ; Gastrointestinal Hemorrhage/diagnostic imaging ; Gastrointestinal Hemorrhage/therapy ; Humans ; Jejunum/pathology ; Portacaval Shunt, Surgical ; Portal Vein/diagnostic imaging ; Portal Vein/pathology ; Portal Vein/surgery ; Tomography, X-Ray Computed ; Treatment Outcome ; Venous Thrombosis/complications ; Venous Thrombosis/diagnostic imaging ; Venous Thrombosis/therapy

Many individuals with short bowel syndrome (SBS) require long-term parenteral nutrition (PN) to maintain adequate nutritional status. Herein, we report a successful intestinal adaptation of a patient with SBS through 13 times intensive nutritional support team (NST) managements. A thirty-five-year-old woman who could not eat due to intestinal discontinuity visited Seoul National University Hospital for reconstruction of the bowel. She received laparoscopic Roux-en-Y gastric bypass (RYGB) due to morbid obesity in Jan 2013 at a certain hospital and successfully reduced her weight from 110 kg to 68 kg. However, after a delivery of the second baby by cesarean section in Jul 2016, most of small bowel was herniated through Peterson’s defect, and emergent massive small bowel resection was performed. Thereafter, she visited our hospital for the purpose of intestinal reconstruction. In Sep 2016, she received side–to-side gastrogastrostomy and revision of double barrel enterostomy. The remaining small bowel included whole duodenum, 30 cm of proximal jejunum, and 10 cm of terminal ileum. Pylorus and ileocecal valves were intact. The patient given only PN after surgery was provided rice-based soft fluid diet after 10 day of operation. Through intensive nutritional management care, she could start solid meals, and finally stop the PN and eat only orally at 45 days postoperatively. Three nutritional interventions were conducted over 2 months after the patient was discharged. She did not require PN during this period, and maintained her weight within the normal weight range. Similar interventions could be used for other patients with malabsorption problems similar to SBS.
Bariatric Surgery* ; Cesarean Section ; Diet ; Duodenum ; Enterostomy ; Female ; Gastric Bypass ; Humans ; Ileocecal Valve ; Ileum ; Jejunum ; Meals ; Nutritional Status ; Nutritional Support ; Obesity, Morbid ; Parenteral Nutrition ; Pregnancy ; Pylorus ; Seoul ; Short Bowel Syndrome*

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.
Anastomosis, Roux-en-Y ; adverse effects ; China ; Chylous Ascites ; etiology ; prevention & control ; therapy ; Duodenum ; blood supply ; surgery ; Gastrectomy ; adverse effects ; methods ; mortality ; Gastric Outlet Obstruction ; etiology ; prevention & control ; Gastric Stump ; surgery ; Hemostatic Techniques ; Hernia ; etiology ; prevention & control ; therapy ; High-Intensity Focused Ultrasound Ablation ; instrumentation ; Humans ; Jejunum ; blood supply ; surgery ; Lymph Node Excision ; adverse effects ; instrumentation ; Lymphatic System ; injuries ; Postoperative Complications ; classification ; diagnosis ; mortality ; prevention & control ; Prognosis ; Stomach ; surgery ; Stomach Neoplasms ; complications ; surgery ; Suture Techniques ; standards ; Thoracic Duct ; injuries ; Wound Closure Techniques ; standards