• bariatric
• bleeding
• endoscopic stapler
• leak
• metabolic
• surgery

• Humans
• Retrospective Studies
• Female
• Male
• Adult
• Surgical Staplers
• Bariatric Surgery/instrumentation
• Bariatric Surgery/methods
• Middle Aged
• Obesity, Morbid/surgery
• Postoperative Complications/epidemiology
• Treatment Outcome
• Laparoscopy/instrumentation
• Laparoscopy/methods
• Surgical Stapling/instrumentation
• United Arab Emirates

• gastric cancer
• laparoscopic-assisted total gastrectomy
• overlap reconstruction
• postoperative complications
• randomized controlled trial
• siewert iii esophagogastric junction cancer
• totally laparoscopic total gastrectomy

• Humans
• Stomach Neoplasms/surgery
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Gastrectomy/methods
• Gastrectomy/adverse effects
• Female
• Male
• Esophagogastric Junction/surgery
• Esophagogastric Junction/pathology
• Middle Aged
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Aged
• Treatment Outcome
• Postoperative Complications/epidemiology
• Adult

• Anastomotic leakage
• Early gastric cancer
• Gastrogastrostomy
• Intracorporeal mechanical anastomosis
• Laparoscopic pylorus-preserving gastrectomy
• Stasis

• Humans
• Stomach Neoplasms/surgery
• Male
• Laparoscopy/methods
• Gastrectomy/methods
• Female
• Retrospective Studies
• Middle Aged
• Pylorus/surgery
• Aged
• Treatment Outcome
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Suture Techniques
• Gastrostomy/methods
• Organ Sparing Treatments/methods
• Neoplasm Staging

• Gastric cancer
• Jejunal interposition double-tract reconstruction
• Laparoscope
• Roux-en-Y reconstruction

• B-I reconstruction
• TLDG
• blood supply
• intracorporeal linear-stapled gastroduodenostomy

• Clinical trials
• Gastrointestinal tumours
• SURGERY

• Anastomosis, Surgical
• Gastrectomy/methods
• Humans
• Laparoscopy/methods
• Prospective Studies
• Quality of Life
• Randomized Controlled Trials as Topic
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Treatment Outcome

• Huashan Hospital Fudan University
• Shanghai Hospital Development Center

Although laparoscopic distal gastrectomy has been widely used for distal gastric cancer, the best functional reconstruction type has not yet been established. Based on previous experience, we propose a modified uncut Roux-en-Y anastomosis. This study aimed to compare the outcomes of different intracorporeal anastomoses after laparoscopic distal gastrectomy.

From April 2015 to August 2020, the data of 215 patients who underwent laparoscopic distal gastrectomy was collected. The patients were divided into 4 groups according to the digestive tract reconstruction method, Billroth-I, Billroth-II, Roux-en-Y, and the modified uncut Roux-en-Y. Clinicopathologic characteristics, surgery details, short-term outcomes, and postoperative nutritional status were analyzed.

The operation time of Billroth-I anastomosis was significantly shorter (216.2 ± 25.8 min, P < .001) than that of other methods. There was no difference in postoperative complications and OS among the 4 reconstruction methods. The incidences of esophagitis, gastritis, and bile reflux were significantly lower in the Roux-en-Y and uncut Roux-en-Y group (P < .001) 1 year after surgery. And the postoperative albumin and PNI levels in uncut Roux-en-Y group were higher than those in other groups(P < .05). On multivariate analysis, age and reconstruction type were independently related to esophagitis, gastritis, and bile reflux. Serum albumin and the prognostic nutritional index were significantly higher in the uncut Roux-en-Y group than other groups (P < .05).

All 4 reconstruction techniques are feasible and safe. The Roux-en-Y and uncut Roux-en-Y are superior to Billroth-Ⅰ and Billroth-Ⅱ+Braun in terms of reflux esophagitis, gastritis, and bile reflux. Uncut Roux-en-Y may result in better PNI than the others.

• bile reflux
• gastric cancer
• laparoscopic surgery
• nutrition
• reconstruction

• Intracorporeal gastric transection
• Marking clips
• Totally laparoscopic gastrectomy

• Double-tract reconstruction (DTR)
• Totally laparoscopic or robotic proximal gastrectomy
• π-shaped esophagojejunostomy

• Billroth-I
• Delta-shaped anastomosis
• Gastric cancer
• Intracorporeal gastroduodenostomy
• Laparoscopic distal gastrectomy

• gastric cancer
• laparoscopic-assisted gastrectomy
• meta-analysis
• safety evaluation
• totally laparoscopic gastrectomy

• delta-shaped anastomosis
• gastric cancer
• self-pulling and latter transected gastrectomy
• totally laparoscopic distal gastrectomy

• Early gastric cancer and remnant stomach
• Gastric stasis
• Laparoscopic pylorus-preserving gastrectomy

• Circular stapler
• Esophagojejunostomy
• Laparoscopic total gastrectomy
• Linear stapler
• Stenosis

• esophageal suspension method
• gastric cancer
• hand-sewn esophagojejunostomy
• suture technique
• totally laparoscopic total gastrectomy

This study evaluated the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy by comparing left dorsal wall anastomosis (LDA) with parallel-line anastomosis (PA) methods.

We retrospectively reviewed 28 patients who underwent laparoscopic total gastrectomy (LTG) for gastric cancer from January 2017 to September 2018. The patients were divided into two groups according to type of operation: 15 patients underwent PA and 13 underwent LDA. Clinico­pathologic characteristics and surgical outcomes in the two groups were compared and analyzed.

Surgical outcomes of estimated blood loss, operation time, and length of postoperative stay were similar between the two groups. In addition, there was no statistical difference in total operation time (186.5±37.0 min vs. 209.0±36.9 min, p=0.121) between the two groups. However, compared with the PA group, the LDA group required fewer additional stitches for reinforcement (p=0.002).

Intracorporeal reconstruction of esophagojejunostomy using an LDA method may be a feasible and easy technique for TLTG compared with the PA method. Additional studies with larger sample sizes are needed to further support these results.

The drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter.

From June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient’s legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series.

No intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30–45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis.

We suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient’s legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

• Adult
• Aged
• Constriction, Pathologic/prevention & control
• Duodenum/injuries
• Duodenum/pathology
• Female
• Gastrectomy/methods
• Gastric Stump/pathology
• Gastroenterostomy/methods
• Humans
• Laparoscopy
• Male
• Middle Aged
• Postoperative Complications
• Postoperative Period
• Retrospective Studies
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Surgical Staplers
• Suture Techniques/instrumentation

In addition to the popularity of laparoscopic gastrectomy (LG), many reconstructive procedures after LG have been reported. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer (GC). Presently, no consensus exists regarding the optimal reconstructive procedure. In this review, the current state of digestive tract reconstruction after LG is reviewed. According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction, we divide these reconstruction procedures into three categories consistent with the resection procedures. We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes (length of surgery and blood loss) and postoperative complications (anastomotic leakage and stricture) to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

• Digestive tract reconstruction
• Laparoscopic gastrectomy
• Gastric cancer
• Quality of life

• Complication
• Esophagojejunostomy
• Gastric cancer
• Laparoscopic surgery
• Total gastrectomy

• hand-sewn
• intracorporeal anastomosis
• laparoscopic gastrectomy
• stomach neoplasms

• Anastomosis, Surgical/methods
• Female
• Gastrectomy/methods
• Gastric Bypass/methods
• Humans
• Laparoscopy/methods
• Lymph Node Excision
• Male
• Middle Aged
• Neoplasm Staging
• Operative Time
• Postoperative Complications
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery

• laparoscopic distal gastrectomy
• network meta-analysis
• reconstruction

• Anastomosis, Roux-en-Y/methods
• Bile Reflux/prevention & control
• Blood Loss, Surgical
• Gastrectomy
• Gastroenterostomy
• Gastrointestinal Motility
• Humans
• Laparoscopy
• Operative Time
• Stomach Neoplasms/surgery

Totally laparoscopic distal gastrectomy (TLDG) frequently involves the use of delta shaped gastroduodenostomy (DSG) for intracorporeal anastomosis. However, DSG has some drawbacks, and the book binding technique (BBT) was developed as a new technique to overcome these drawbacks. Subsequently, this technique was further improved with the development of modified book binding technique (MBBT). This study evaluated the safety and feasibility of MBBT in patients undergoing TLDG. Thirty-three patients who underwent TLDG with MBBT were retrospectively evaluated. The mean operation time was 277.6±37.1 minutes, including 51.9±15.7 minutes for reconstruction. Two patients had anastomosis-related complications, one patient with stricture after leakage and 1 patient with stenosis. The former patient was treated with endoscopic balloon dilatation, and the latter was managed conservatively; neither required re-operation. MBBT is a safe and feasible technique, with acceptable surgical outcomes. It may be a good alternative option for the treatment of intracorporeal anastomosis in patients undergoing TLDG.

• Gastrectomy
• Gastric cancer
• Laparoscopy
• Surgical anastomosis

Gastric cancer is the fourth most common malignant disease worldwide, with lower one-third gastric cancer the most common type. Distal gastrectomy with D2 lymph node dissection was recommended as a standard surgery for distal gastric cancer patients. However, some controversy remains about the anastomosis of the residual stomach and the intestine. The objectives of this trial are to test the hypothesis that uncut Roux-en-Y anastomosis can reduce postoperative complications and improve nutritional status more effectively than Billroth II anastomosis in gastric cancer patients after D2 gastrectomy.

This multi-center, prospective, phase III, randomized controlled trial will compare the efficacy of uncut Roux-en-Y anastomosis versus Billroth II anastomosis in phase I–III patients with initial treatment of radical distal gastrectomy. Patients will be randomized to undergo either the intervention (uncut Roux-en-Y anastomosis) or the control (Billroth II anastomosis). We will recruit 832 patients who meet the trial eligibility criteria and will follow the patients after surgery to observe postoperative complications and nutrition status for 5 years. The primary assessment indices of the study are reflux gastritis, esophagitis, bile regurgitation, and anastomotic ulcer. The secondary assessment indices are nutritional status, quality of life, perioperative complications, overall survival rate, and others. When the number of cases reaches 400, an interim analysis will be performed to identify any evidence of definite superiority of the experimental intervention.

We aim to test the hypothesis that uncut Roux-en-Y anastomosis can reduce postoperative complications and improve nutritional status more than Billroth II anastomosis in gastric cancer patients after D2 gastrectomy. The results of the trial will contribute to the best evidence on which to base the reconstruction of distal gastrectomy.

Chinese Southern Gastric Cancer Conference CSGC002 Trial. ClinicalTrials.gov, NCT02763878. Registered on 5 May 2016.

The online version of this article (10.1186/s13063-019-3531-0) contains supplementary material, which is available to authorized users.

• Billroth II anastomosis
• D2 distal gastrectomy
• Nutritional status
• Uncut Roux-en-Y anastomosis

• Gastrectomy
• Laparoscopy
• Stomach neoplasm
• Surgical anastomosis

• Body mass index
• Extracorporeal gastroduodenostomy
• Gastric cancer
• Intracorporeal gastroduodenostomy
• Laparoscopic distal gastrectomy
• Surgical injuries

• Billroth-I reconstruction
• Gastric cancer
• Laparoscopic distal gastrectomy
• Roux-en-Y reconstruction

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).

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.

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.

IDA is safe and feasible and shows more satisfactory short-term outcomes than EA.

• Colon cancer
• delta-shaped anastomosis
• digestive-tract reconstruction
• intra-corporeal anastomosis
• laparoscopic right hemicolectomy

• Roux-en-Y reconstruction
• circular-stapled anastomosis
• intracorporeal gastrojejunostomy
• intracorporeal jejunojejunostomy
• intraluminal poke technique
• laparoscopic distal gastrectomy

• Intracorporeal esophageojejunostomy
• Robotic total gastrectomy
• π-Shaped esophagojejunostomy

Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis is feasible because of improved approaches to laparoscopic surgery and the availability of a variety of surgical instruments. This study was designed to evaluate the practicality, safety and short-term operative outcomes of intracorporeal gastroduodenostomy in TLDG for gastric cancer.

Medical records of patients with primary distal gastric cancer undergoing Billroth I (B-I) (n = 37) or B-II anastomosis (n = 41) in TLDG from February 2010 to November 2015 were retrospectively analysed. Perioperative data including the extent of lymph node dissection, number of stapler cartridges used, time required to create the anastomosis, operative time, estimated blood loss, proximal and distal margin length, and number of lymph nodes harvested were collected. Short-term post-operative outcomes evaluated during the initial 30 days after surgery included time to first flatus and earliest liquid consumption, length of post-operative hospital stay and incidence of post-operative complications.

B-I anastomosis was mainly applied to patients with carcinoma in the lower third of the gastric body (B-I, 81.08% vs. B-II, 31.71%; P < 0.001). Mean operating (B-I, 153.57 ± 18.25 min vs. B-II, 120.17 ± 11.74 min; P = 0.004) and anastomosis (B-I, 31.92 ± 6.10 min vs. B-II, 25.29 ± 3.84 min; P = 0.01) times were significantly longer for B-I anastomosis compared to B-II anastomosis. There were no significant differences in the number of stapler cartridges used, estimated blood loss, time to first flatus and liquid consumption, length of hospital stay or incidence of complications between these groups.

TLDG with B-I or B-II anastomosis is safe and feasible for gastric cancer. B-II anastomosis may require less time than B-I anastomosis.

• Billroth I anastomosis
• Billroth II anastomosis
• gastric cancer
• intracorporeal anastomosis
• laparoscopic distal gastrectomy
• totally laparoscopic gastrectomy

• Barbed suture
• Esophagojejunostomy
• Gastric cancer
• Intracorporeal anastomosis
• Laparoscopic surgery
• Roux-en-Y reconstruction
• Total gastrectomy

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Roux-en-Y/adverse effects
• Anastomosis, Roux-en-Y/methods
• Feasibility Studies
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastroenterostomy/adverse effects
• Gastroenterostomy/methods
• Gastroscopy/instrumentation
• Humans
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Lymph Node Excision/methods
• Lymphatic Metastasis
• Male
• Middle Aged
• Neoplasm, Residual/etiology
• Nutritional Status
• Operative Time
• Postoperative Complications/etiology
• Prospective Studies
• Retrospective Studies
• Stomach Neoplasms/surgery
• Surgical Staplers
• Treatment Outcome

• Early gastric cancer
• Intracorporeal end-to-end gastrogastrostomy
• Mechanical anastomosis
• Piercing method
• Totally laparoscopic pylorus-preserving gastrectomy

To evaluate the safety and feasibility of enhanced recovery after surgery (ERAS) for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy.

The clinical data of 42 patients who were divided into an ERAS group (n = 20) and a control group (n = 22) were collected. The observed indicators included operation conditions, postoperative clinical indexes, and postoperative serum stress indexes. Measurement data following a normal distribution are presented as mean ± SD and were analyzed by t-test. Count data were analyzed by χ² test.

The operative time, volume of intraoperative blood loss, and number of patients with conversion to open surgery were not significantly different between the two groups. Postoperative clinical indexes, including the time to initial anal exhaust, time to initial liquid diet intake, time to out-of-bed activity, and duration of hospital stay of patients without complications, were significantly different between the two groups (t = 2.045, 8.685, 2.580, and 4.650, respectively, P < 0.05 for all). However, the time to initial defecation, time to abdominal drainage-tube removal, and the early postoperative complications were not significantly different between the two groups. Regarding postoperative complications, on the first and third days after the operation, the white blood cell count (WBC) and C reactive protein (CRP) and interleukin-6 (IL-6) levels in the ERAS group were significantly lower than those in the control group.

The perioperative ERAS program for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy is safe and effective and should be popularized. Additionally, this program can also reduce the duration of hospital stay and improve the degree of comfort and satisfaction of patients.

• Distal gastrectomy
• Enhanced recovery after surgery
• Perioperative period
• Uncut Roux-en-Y gastrojejunostomy

• Aged
• Blood Loss, Surgical/statistics & numerical data
• C-Reactive Protein/analysis
• Conversion to Open Surgery/statistics & numerical data
• Feasibility Studies
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastric Bypass/adverse effects
• Gastric Bypass/methods
• Humans
• Interleukin-6/blood
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Length of Stay/statistics & numerical data
• Leukocyte Count
• Male
• Middle Aged
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Period
• Retrospective Studies
• Stomach Neoplasms/blood
• Stomach Neoplasms/surgery

We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.

• additional knotted suture
• barbed suture
• delta-shaped gastroduodenostomy
• gastric cancer
• totally laparoscopic distal gastrectomy

• Esophagojejunostomy
• Later-cut
• Overlap
• Quality of life
• Totally laparoscopic total gastrectomy

• Adult
• Aged
• Anastomosis, Roux-en-Y/adverse effects
• Chi-Square Distribution
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Humans
• Jejunum/surgery
• Laparoscopy/adverse effects
• Male
• Middle Aged
• Postoperative Complications/etiology
• Propensity Score
• Quality of Life
• Plastic Surgery Procedures/adverse effects
• Plastic Surgery Procedures/methods
• Retrospective Studies
• Risk Factors
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Surveys and Questionnaires
• Time Factors
• Treatment Outcome

• Esophagojejunal anastomotic leakage
• Gastric cancer
• Risk factor
• Total gastrectomy
• Treatment

• Complete double stapling technique (cDST)
• extracorporeal Billroth-I anastomosis
• laparoscopy-assisted distal gastrectomy (LADG)

• Billroth-II anastomosis
• Gastric cancer
• Laparoscopic gastrectomy
• Surgical outcome

• esophagojejunostomy
• intracorporeal
• purse-string instrument
• total gastrectomy

• GI tract reconstruction
• Gastric cancer
• Laparoscopy
• Uncut Roux-en-Y anastomosis

• Anastomotic technique
• Esophagojejunostomy
• Gastric cancer
• Laparoscopic total gastrectomy

• Locally advanced
• Modified delta-shaped gastroduodenostomy
• Stomach neoplasms
• Totally laparoscopic surgery

• Adult
• Aged
• Aged, 80 and over
• Case-Control Studies
• Female
• Gastrectomy/methods
• Gastroenterostomy/methods
• Humans
• Laparoscopy/methods
• Lymph Node Excision
• Male
• Middle Aged
• Multivariate Analysis
• Postoperative Complications
• Propensity Score
• Stomach Neoplasms/surgery
• Treatment Outcome
• Young Adult

• Fujian province Health Planning Commission medical innovation project
• Natural fund project of Science and Technology Department of Fujian Province