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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 1-5

A modified uncut roux-en-y anastomosis in laparoscopic-assisted distal gastrectomy: Balance of the cost and minimally invasion


Department of Gastrointestinal Surgery, Shanghai East Hospital (East Hospital Affiliated to Tongji University), Shanghai, China

Date of Submission15-Oct-2017
Date of Acceptance31-Jan-2018
Date of Web Publication22-Mar-2018

Correspondence Address:
Xiaohua Jiang
Department of Gastrointestinal Surgery, Shanghai East Hospital (East Hospital Affiliated to Tongji University), 150 Jimo Road, Shanghai 200120
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_20_17

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  Abstract 


Aim: The aim of the study was to evaluate the cost of minimally invasive surgery using a modified uncut Roux-en-Y anastomosis technique in laparoscopic distal radical gastrectomy patients with gastric cancer. Methods: Clinical and cost data were reviewed on the perioperative outcomes of 15 gastric cancer patients who received laparoscopic distal radical gastrectomy using uncut Roux-en-Y anastomosis from January 2016 to December 2016 in the Department of Gastrointestinal Surgery, Shanghai East Hospital. Results: The mean operation time was 175 ± 30 min. Mean hospitalization expense was 9829 USD and mean linear stapler expense was 2940 USD. Laparoscopic distal radical gastrectomy with uncut Roux-en-Y anastomosis was successfully carried out in all the patients. There were no serious complications and no death in this series. Conclusion: Modified uncut Roux-en-Y anastomosis in laparoscopic distal radical gastrectomy may be a good way to balance the cost and minimally invasive surgery.

Keywords: Gastric cancer, laparoscopy, uncut Roux-en-Y anastomosis


How to cite this article:
Zhang S, Du T, Yan D, Jiang X, Song C. A modified uncut roux-en-y anastomosis in laparoscopic-assisted distal gastrectomy: Balance of the cost and minimally invasion. Transl Surg 2018;3:1-5

How to cite this URL:
Zhang S, Du T, Yan D, Jiang X, Song C. A modified uncut roux-en-y anastomosis in laparoscopic-assisted distal gastrectomy: Balance of the cost and minimally invasion. Transl Surg [serial online] 2018 [cited 2018 Apr 25];3:1-5. Available from: http://www.translsurg.com/text.asp?2018/3/1/1/228310




  Introduction Top


Gastric cancer is the second leading cause of cancer deaths worldwide. China has a high incidence of gastric cancer.[1] Radical surgical resection remains the most effective treatment for gastric cancer.[2] Digestive tract reconstruction is a critical aspect of the procedure in addition to the oncologic goals of disease resection.

There are several reconstruction methods of digestive tract after laparoscopic distal gastrectomy including Billroth I,[3] Billroth II,[4] and Roux-en-Y anastomosis.[5] An optimal technique of digestive tract reconstruction after distal gastrectomy has not yet been established. Roux-en-Y gastrojejunostomy is now used worldwide for the prevention of alkaline reflux gastritis, esophagitis, dumping syndrome, and carcinogenesis of the gastric remnant. However, more than one-third of the patients suffer from Roux stasis syndrome which consists of nausea, vomiting, abdominal discomfort, and bloating after meals.[6] It has been proposed that the occurrence of Roux stasis syndrome is related to the interruption of electrical conduction caused by amputation of the jejunum.[7] The uncut Roux-en-Y gastrojejunostomy is a modified technique based on the Billroth II operation with Braun anastomosis. Previous studies indicated that the uncut operation incorporating the occlusion step may reduce the incidence of the Roux stasis syndrome and prevent alkaline reflux.[8]

Laparoscopic surgery was introduced into clinical practice 30 years ago as an approach to minimally invasive surgery. The use of the laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy has been conducted for many years.[9] Surgeons seek to improve the Roux-en-Y anastomosis. The uncut version may maximize intraoperative efficiency, improve cost profile, and improve safety.

Although totally laparoscopic distal gastrectomy with uncut Roux-en-Y anastomosis offers many benefits, it remains an expensive procedure,[10] especially in China, where health-care systems face greater economic pressure due to financial constraints.[11] The financial resource shortage crisis has challenged many Chinese medical centers to control costs and resource utilization associated with laparoscopic surgery.

In this retrospective study, we report our experience with 15 successful modified laparoscopic-assisted uncut Roux-en-Y gastrojejunostomy following distal gastrectomy to evaluate feasibility, safety, cost-effectiveness, and short-term outcomes.


  Methods Top


Patients

Between January 2016 and December 2016, 15 patients underwent laparoscopic-assisted distal gastrectomy with D2 regional lymph node dissection. The tumor location and adequate proximal resection margins were confirmed by surgeons through visualization and palpation. Resected proximal margins were sent for frozen pathology when close margins were suspected.

This study was performed according to the ethical standards of the Helsinki Declaration of 1964 (revised in 2008) and approved by an Institutional Review committee. Informed consent was obtained from all of the patients before the operation.

Variables

Patient variables included age, sex, the extent of lymph node dissection, the anastomotic method, laparotomy conversions and intraoperative complications, the time required for anastomosis, the operation time, the estimated blood loss, the number of days to first flatus, the number of days on a liquid diet, the length of postoperative hospital stay, hospital costs, and postoperative complications.

Surgical technique

The surgical procedures were performed using a five-trocar system. The distal gastrectomy with D2 lymph node dissection was performed following the Japanese gastric cancer treatment guidelines [12] according to the preoperative staging.

Modified uncut Roux-en-Y gastrojejunostomy

After lymph node dissection, the duodenum was transected 2 cm from the pylorus with a laparoscopic 45 mm or 60 mm linear stapler [Figure 1]a. Under direct vision, the stomach was transected using two 60 mm laparoscopic linear staples that were approximately 5 cm proximal to the tumor [Figure 1]b.
Figure 1: Transecting the specimen and marking the uncut site. (a) Transecting the duodenum. (b) Transecting the stomach. (c) Marking the uncut site. (d) Placing the specimen into sample bag

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The transverse colon was retracted cephalad to expose the ligament of Treitz, and the jejunum was marked 20 cm distal to this ligament [Figure 1]c. The jejunal mesentery was penetrated by laparoscopic surgical pliers and then encircled by full-extent 2-0/T Mersilk and externalized. The en bloc gastric specimen was removed using a self-made specimen bag through an extended 12 mm trocar site [Figure 1]d. The surgeon then inspected the specimen margins extracorporeally [Figure 2]a.
Figure 2: Taking off and checking the specimen. (a) Checking the incisal margin extracorporeally. (b) Stapling across the uncut line

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An extracorporeal stapler (two-row staplers, RLS6035S, Reach Surgical, China) was placed across the externalized afferent jejunum 20 cm distal to the Treitz ligament and fired without the cutting step [Figure 2]b. To avoid postoperative recanalization, interrupt lock-stitch sutures were performed using 2-0/T Mersilk [Figure 3]a. Next, a Braun anastomosis was created. The proximal and distal jejunum were anastomosed to form a side-to-side jejunojejunostomy using a liner stapler [Figure 3]b. The anastomotic stoma was established 15 cm (5 cm afferent to the occlusion) and 50 cm (30 cm afferent to the occlusion) away from the Treitz ligament. The common enterotomy was closed extracorporeally by a single layer of continuous running suture (Covidien 3-0 Caprosyn, Mansfield, MA, US).
Figure 3: Handle the uncut site. (a) Interrupt lock-stitch sutures. (b) Performing a side-to-side jejunojejunostomy

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A small opening was made at the jejunum on the antimesenteric border 25 cm away from the Treitz ligament [Figure 4]a. The operation then returned again to a laparoscopic procedure. Another opening was made at the stapling line on the greater curvature side of the gastric stump. Next, using a laparoscopic linear stapler, an antecolic afferent loop to lesser curvature side-to-side gastrojejunostomy was performed [Figure 4]b. The common enterotomy was closed intracorporeally by a single layer of continuous running suture (Covidien V-Loc 3-0, Mansfield, MA, US) [Figure 5]a.
Figure 4: Performing a side-to-side jejunojejunostomy. (a) Marking the gastrojejunostomy site. (b) Performing a side-to-side gastrojejunostomy

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Figure 5: Performing a side-to-side gastrojejunostomy. (a) Close the common entry. (b) Uncut Roux-en-Y gastrojejunostomy

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The completed uncut Roux-en-Y gastrojejunostomy was shown in [Figure 5]b. For this method, five laparoscopic linear staplers were used: one stapler for the duodenal resection, two staplers for the gastric resection, one stapler for the jejunojejunostomy, and one stapler for gastrojejunostomy. One stapler without a blade was also used to block the afferent jejunum. The surgeon stood on the right side of the patient when performing gastrojejunostomy and on the left side when performing all the other procedures.


  Results Top


Between January 2016 and December 2016, we performed laparoscopic distal gastrectomy with D2 dissection and modified uncut Roux-en-Y gastrojejunostomy for gastric cancer in 15 patients. All procedures were completed without conversion to open surgery.

Fifteen cases, including nine males and six females, were involved in this study. Median age was 65 (38–84) years. None postoperative mortality was noted. Mean operative time was 175 ± 30 min including anastomotic time 30 ± 15 min. Estimated blood loss was 50 ± 40 mL. Time to first flatus was 2 days (range 1–3 days), and postoperative hospital stay was 8 days (range 7–12 days). Mean hospitalization expense was 9829 USD and mean linear stapler expense was 2940 USD. None of the postoperative complications such as anastomosis leakage, anastomotic stenosis, duodenal stump fistula, and Roux stasis syndrome was observed.

During a short-term follow-up period of 9 months (range: 5–17 months), we did not observe any cases of long-term postoperative complication (>30 days after surgery), recurrence, nor any cancer-related mortality. There were no staple line dehiscence events.


  Discussion Top


Although minimally invasive surgery is unquestionably the preferred therapy for most patients with gastric cancer, the higher cost associated with the laparoscopic approach, and particularly that of the linear staple devices, poses a heavy burden on both governments and patients in developing countries. In China, many medical centers are increasingly under pressure to identify major determinants of cost and ways of controlling them. We report a method of laparoscopic-assisted uncut Roux-en-Y gastrojejunostomy after distal gastrectomy to balance the costs of minimally invasive treatment.

The theories and advantages of uncut Roux-en-Y reconstruction

The type of digestive tract reconstruction is a determining factor for postoperative quality of life and is a topic of concern among surgeons. The Billroth I anastomosis can maintain the anatomical structures of the alimentary tract. However, this method only applies to early stages of lower stomach carcinoma with tumors located at least 2 cm away from the pylorus. A Billroth II anastomosis is technically simple; however, it has a higher incidence of postoperative reflux gastritis as well as gastric stump cancer. The Roux-en-Y gastrojejunostomy is currently considered a valid reconstruction method after distal gastrectomy for gastric cancer. The main advantage of the Roux-en-Y procedure is that it forms a tension-free anastomosis, effectively prevents digestive fluid refluxes, and has a lower incidence of postoperative remnant gastritis, anastomotic stoma fistula, and stricture.[13]

Nevertheless, Roux-en-Y reconstruction may cause Roux stasis syndrome with a reported incidence up to 30%. Patients with Roux stasis syndrome present with nausea, vomiting, epigastric pain, and weight loss. The pathogenesis of Roux stasis is thought to be associated with electrical and motor abnormalities in the Roux limb resulting from transection of the jejunum.[14] Uncut Roux-en-Y gastrojejunostomy is a modification of the Billroth II procedure with Braun anastomosis. Theoretically, an uncut Roux-en-Y procedure not only maintains the integrity of the intestinal canal and normal conduction of impulses but also promotes direct drainage of gastric contents into the intestinal tract along the physiologic direction of movement. This may serve to alleviate alkaline reflux gastritis, esophagitis, and Roux stasis syndrome.[15] As an added bonus, the uncut operation significantly reduces the amount of intraoperative bleeding and operative time due to the absence of a mesenteric defect.

The challenges of laparoscopic distal gastrectomy with uncut Roux-en-Y anastomosis

The use of laparoscopic treatments for gastric cancer is increasing due to the advantages of minimally invasive surgery. Many trials have evaluated the oncological feasibility and safety of laparoscopic distal gastrectomy with uncut Roux-en-Y anastomosis.[16] In 2005, Uyama et al.[17] published a report regarding the laparoscopic-assisted uncut Roux-en-Y gastrojejunostomy after distal gastrectomy. In 2008, Kim et al.[10] reported the outcomes of 28 successful total laparoscopic distal gastrectomies with an uncut Roux-en-Y gastrojejunostomy and showed the safety and practicability of the total laparoscopic operation in terms of its technical aspects. In 2014, intracorporeal uncut Roux-en-Y gastrojejunostomy through pure single-incision laparoscopic distal gastrectomy was first reported by Ahn et al.[18]

Some challenges associated with the use of uncut Roux-en-Y reconstruction in clinical practice still need to be overcome. Previous studies indicated staple-line dehiscence in patients who had undergone the uncut Roux technique.[19] Potential reasons cited include a change in anastomotic shape using a nonbladed linear stapler from a “B” to a “C” shape due to peristalsis and intraluminal pressure, particularly if the staple line was not completely occluded.

In our experience, the bladeless linear stapler (ETS Flex45 no-knife endoscopic articulating linear stapler, Ethicon Endo-Surgery, Cincinnati, OH, US) is the key instrument [10],[18] but is not readily available in China at this time. Chinese surgeons often use a suture ligation method to occlude the jejunal lumen.[20] Given advancing technology, it is likely that a more effective method/device will be invented that can achieve permanent occlusion of the proximal jejunum without transaction.[21]

Our contribution to an improved laparoscopic-assisted uncut Roux-en-Y anastomosis

We performed 15 laparoscopic-assisted uncut Roux-en-Y operations following distal gastrectomy, and the postoperative courses in most of the patients were uneventful. In our study, the jejunojejunostomy with uncut occlusion was conducted extracorporeally. The entire anastomotic procedure can be clearly viewed. The distances of the remnant stomach–jejunum anastomosis, Braun anastomosis, the jejunal occlusion site, and the length of the proximal and distal limbs can be measured precisely.

The most significant problem with the uncut Roux-en-Y operation, was the frequent recanalization of the afferent loop, which allows bile to access to the gastric remnant. We performed extracorporeal stapling and Braun anastomosis before intracorporeal gastrojejunostomy. Currently, the most popular method of jejunal occlusion is stapling with a six-row linear stapler.[7] We used a two-row, bladeless, linear stapler with interrupted locking sutures. The occluded limb was reinforced with silk for the reason that it is inert and nonabsorbable. There were no cases of recanalization in our follow-up, possibly as a result of our modification.

In our modified procedure, we evaluated our use of staplers and duration of surgery. With a routine uncut Roux-en-Y anastomosis, 7–8 laparoscopic linear staples were used: one stapler for the duodenal resection, two staplers for the gastric resection, one stapler for gastrojejunostomy, and one stapler for the jejunojejunostomy. Two laparoscopic linear staplers were needed to close the common entry hole of gastrojejunostomy and jejunojejunostomy. The bladeless two-row linear stapler was used a less expensive alternative to a four- or six-row stapler. Therefore, the mean linear stapler expense was 4446 USD and the mean operation time was 190 ± 25 min for a routine uncut Roux-en-Y anastomosis in our center. For added cost savings, the jejunojejunostomy can be hand-sewed.

For this described method, five laparoscopic linear staples were used. Cost savings can be improved by performing a hand-sewn jejunojejunostomy using a slightly extended incision. The bladeless two-row linear stapler is also less expensive than a four- or six-row stapler. These alterations in technique may act as cost-saving measures that balance the overall increased costs of a laparoscopic approach.

Our modified laparoscopic-assisted uncut Roux-en-Y operation after distal gastrectomy is both feasible and safe. Additional modifications regarding the number of staplers used may increase the cost. This operation represents a reasonable alternative to standard approaches for laparoscopic distal gastrectomy.

Financial support and sponsorship

The study was supported by Leader of Health System in Shanghai Pudong New District (No. PWRD2014-04) and Science and Technology Commission of Shanghai (No. 14 ZR1433800).

Conflicts of interest

There are no conflicts of interest.



 
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Jeong O, Jung MR, Park YK, Ryu SY. Safety and feasibility during the initial learning process of intracorporeal Billroth I (delta-shaped) anastomosis for laparoscopic distal gastrectomy. Surg Endosc 2015;29 (6):1522-9.  Back to cited text no. 3
    
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Inokuchi M, Kojima K, Yamada H, Kato K, Hayashi M, Motoyama K, Sugihara K. Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy. Gastric Cancer 2013;16 (1):67-73.  Back to cited text no. 5
    
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Xiong JJ, Altaf K, Javed MA, Nunes QM, Huang W, Mai G, Tan CL, Mukherjee R, Sutton R, Hu WM, Liu XB. Roux-en-Y versus Billroth I reconstruction after distal gastrectomy for gastric cancer: A meta-analysis. World J Gastroenterol 2013;19 (7):1124-34.  Back to cited text no. 13
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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