From Billroth to PCV: a century of gastric surgery

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis

BACKGROUND

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness.

METHODS

Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups.

RESULTS

During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively.

CONCLUSION

R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

Surgical Sealant with Integrated Shape-Morphing Dual Modality Ultrasound and Computed Tomography Sensors for Gastric Leak Detection

Postoperative anastomotic leaks are the most feared complications after gastric surgery. For diagnostics clinicians mostly rely on clinical symptoms such as fever and tachycardia, often developing as a result of an already fully developed, i.e., symptomatic, surgical leak. A gastric fluid responsive, dual modality, electronic-free, leak sensor system integrable into surgical adhesive suture support materials is introduced. Leak sensors contain high atomic number carbonates embedded in a polyacrylamide matrix, that upon exposure to gastric fluid convert into gaseous carbon dioxide (CO2 ). CO2 bubbles remain entrapped in the hydrogel matrix, leading to a distinctly increased echogenic contrast detectable by a low-cost and portable ultrasound transducer, while the dissolution of the carbonate species and the resulting diffusion of the cation produces a markedly reduced contrast in computed tomography imaging. The sensing elements can be patterned into a variety of characteristic shapes and can be combined with nonreactive tantalum oxide reference elements, allowing the design of shape-morphing sensing elements visible to the naked eye as well as artificial intelligence-assisted automated detection. In summary, shape-morphing dual modality sensors for the early and robust detection of postoperative complications at deep tissue sites, opening new routes for postoperative patient surveillance using existing hospital infrastructure is reported.

Propensity score matching comparisons of postoperative complications and morbidity between digestive tract reconstruction methods after gastrectomy in gastric cancer patients with visceral obesity

Background

Few studies have compared the prognosis of different reconstruction methods after gastrectomy for gastric cancer (GC) patients with obesity. The aim of the present study was to compare postoperative complications and overall survival (OS) between the following reconstruction methods: Billroth I (B-I), Billroth II (B-II), and Roux-en-Y (R-Y) after gastrectomy for GC patients with visceral obesity (VO).

Methods

We performed a double-institutional dataset study of 578 patients who underwent radical gastrectomy with B-I, B-II, and R-Y reconstructions between 2014 and 2016. VO was defined as a visceral fat area at the level of the umbilicus greater than 100 cm². Propensity score-matching analysis was performed to balance the significant variables. Postoperative complications and OS were compared between the techniques.

Results

VO was determined in 245 patients, of which 95, 36, and 114 underwent B-I, B-II, and R-Y reconstructions, respectively. B-II and R-Y were fused into the Non-B-I group due to the similar incidence of overall postoperative complications and OS. Therefore, 108 patients were enrolled after matching. The overall postoperative complications incidence and overall operative time in the B-I group were significantly lower than those in the non-B-I group. Further, multivariable analysis showed that B-I reconstruction was an independent protective factor for overall postoperative complications (odds ratio (OR) 0.366, P=0.017). However, no statistical difference in OS was found between the two groups (hazard ratio (HR) 0.644, P=0.216).

Conclusions

B-I reconstruction was associated with decreased overall postoperative complications, rather than OS, in GC patients with VO who underwent gastrectomy.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy

PURPOSE

This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively.

METHODS

We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5).

RESULTS

Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups.

CONCLUSIONS

L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

Epidemiology of Helicobacter pylori

In many countries alike, the time trends of gastric cancer, gastric and duodenal ulcer, ulcerative colitis, Crohn's disease, and colorectal cancer are characterized by similar birth-cohort patterns. Mortality from these diagnoses rose in cohorts born during the 19th century and then fell in subsequent cohorts born during the 20th century.

Early Diagnosis of Anastomotic Leakage After Gastric Cancer Surgery Via Analysis of Inflammatory Factors in Abdominal Drainage

BACKGROUND

Anastomotic leakage (AL) is the most serious postoperative complication for patients with gastric cancer. We aim to develop clinically tools to detect AL in the early phase by analysis of the inflammatory factors (IFs) in abdominal drainage.

METHODS

We prospectively included 326 patients to establish two independent cohorts, and the concentration of IFs within abdominal drainage was detected. In the primary cohort, an IF-based AL prediction model was constructed using the least absolute shrinkage and selection operator (LASSO) regression. The predictive value of the model was later validated via the validation cohort.

RESULTS

Analyzing the IFs with LASSO regression, we developed an Anastomotic Score system on postoperative Day 3 (AScore-POD3), which yielded high diagnostic efficacy in the primary cohort (the area under the curve (AUC) = 0.87). The predictive value of AScore-POD3 was validated in the validation cohort, and its AUC was 0.83. We further built an AScore-POD3 based nomogram by combining the AScore-POD3 system with other clinical risk factors of AL. The C-index of the nomogram was 0.93 in the primary cohort and 0.82 in the validation cohort.

CONCLUSIONS

Our study suggests that AL can be early diagnosed after gastric cancer surgery by measuring drainage IFs.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

Functional Outcomes of Delta-Shaped Anastomosis After Laparoscopic Distal Gastrectomy

BACKGROUND

We invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings.

METHODS

The medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings.

RESULTS

The operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only.

CONCLUSIONS

Functional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

Comparison of 5-year postoperative outcomes after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: Results from a multi-institutional randomized controlled trial

AIM

We previously reported in a randomized controlled trial that Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change and nutritional status 1 year after distal gastrectomy for gastric cancer. We describe the long-term follow-up data 5 years after distal gastrectomy.

METHODS

We analyzed consecutive gastric cancer patients who were randomly assigned to undergo Billroth I or Roux-en-Y reconstruction after distal gastrectomy. We evaluated body weight change, nutritional status, late complications, quality of life (QOL) using the European Organization for Research and Treatment of Cancer Core QOL Questionnaire, and dysfunction using the Dysfunction After Upper Gastrointestinal Surgery for Cancer, 5 years after surgery.

RESULTS

A total of 228 patients (Billroth I = 105; Roux-en-Y = 123) were eligible for efficacy analyses in this study. Body weight loss 5 years after surgery did not differ significantly between the Billroth I and Roux-en-Y groups (10.0% ± 7.9% and 9.6% ± 8.4%, respectively; P = .70). There were no significant differences in other aspects of nutritional status between the two groups. Reflux esophagitis occurred in 19.0% of the patients in the Billroth I group vs 4.9% in the Roux-en-Y group (P = .002). Regarding QOL, Billroth I was significantly inferior to Roux-en-Y on the diarrhea scale (Billroth I: 28.6, Roux-en-Y: 16.0; P = .047). Regarding dysfunction, no score differed significantly between the two groups.

CONCLUSIONS

Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change, nutritional status, and QOL 5 years after distal gastrectomy, although Roux-en-Y more effectively prevented reflux esophagitis and diarrhea.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

Propensity-score-matched analysis of a multi-institutional dataset to compare postoperative complications between Billroth I and Roux-en-Y reconstructions after distal gastrectomy

BACKGROUND

Few well-controlled studies have compared postoperative complications between Billroth I (B-I) and Roux-en-Y (R-Y). The aim of the present study was to compare the incidence of overall and severe postoperative complications by reconstruction method after distal gastrectomy.

METHODS

We performed a multi-institutional dataset study of patients who underwent distal gastrectomy with B-I or R-Y reconstruction from 2010 to 2014. Using propensity scores to strictly balance the significant variables, we compared postoperative complications between the techniques.

RESULTS

After matching, we enrolled 1014 patients (n = 507 in each group). The incidence of postoperative complications in the R-Y group was significantly higher vs the B-I group (29% vs 17%, P < 0.0001). The incidence of intra-abdominal abscess (4.3% vs 1.8%, P = 0.0177), bowel obstruction (2.6% vs 0.6%, P = 0.0203), and delayed gastric emptying (5.3% vs 1.0%, P < 0.0001) in the R-Y group was significantly higher vs the B-I group, respectively; we saw no significant difference in leakage (3.4% vs 4.1%, P = 0.5084). The incidence of grade ≥ III severe postoperative complications in the R-Y group was significantly higher vs the B-I group (13% vs 7.1%, P = 0.0013). Multivariable analysis showed that R-Y reconstruction was a strong independent risk factor for overall postoperative complications (odds ratio 1.58, P = 0.0044) and grade ≥ III severe postoperative complications (odds ratio 1.75, P = 0.0127). A forest plot revealed that R-Y reconstruction was associated with a greater risk of both overall and grade ≥ III severe postoperative complications in any subgroups.

CONCLUSIONS

R-Y reconstruction was associated with increasing overall postoperative complications, as well as severe postoperative complications.

Gastric Cancer in History: A Perspective Interdisciplinary Study

Background: Gastric adenocarcinoma is the fourth most common type of cancer and the second leading cause of cancer death in the world. Despite abundant traces of an ancient history, the comprehension of its pathogenic mechanisms is rather recent and continuously updated. Methods: We investigated about how the ancient civilizations tried to understand the exactly physiopathology of gastric cancer, from the time when they could not examine deeply the histological and pathophysiologic aspects of the disease, but they just based their knowledge on a visual analysis of the signs and consequences of such disease. We examined the historical evolving knowledge of the disease along the centuries on the gastroenterological, pharmacological, and surgical fields, defining how gastric cancer became an increasingly curable disease. Results: Cancer was known in the ancient world. Ancient people did not know exactly the causes but the climatic, hygienic, and food conditions were the first to be considered over time, also taking into consideration supernatural negative influences. During the Renaissance, a tumultuous time of scientific discoveries started, thanks to an increasing number of autopsies made on cadavers and to the progressions in visual analysis of the stomach mucosa throughout endoscopy. From the first gastric surgery in 1879, many steps forward have been made and, today, gastric cancer is regarded as a more curable disease; one important discovery in this field has been the revelation of the role of Helicobacter pylori in the peptic ulcer disease (PUD) and in some forms of gastric lymphoma. Conclusions: Gastric cancer has the fourth highest incidence of various cancers worldwide and is ranked second as a cause of cancer-related death. It exists from the antiquity and a lot of hypotheses have been developed about its etiology during the centuries, influencing its therapy. During the 20th century, thanks to the scientific and technological progresses the causes of the cancer have been discovered and the role of the bacterium Helicobacter pylori has been demonstrated, and new perspective research are currently trying to investigate the role of other microorganisms in gastric physiopathology, as well as its possible modulation by probiotics.

Trends in Major Gastrectomy for Cancer: Frequency and Outcomes

BACKGROUND

Declining incidence of gastric cancer in the USA has presumably resulted in lower rates of major gastrectomy for cancer. The impact on perioperative outcomes remains undefined. The aims of this study were to characterize national trends in frequency of major gastrectomy for cancer, identify factors associated with in-hospital mortality, and examine outcome disparities by race/ethnicity.

METHODS

Nationwide inpatient sample data from 1993 to 2013 were queried for procedural and diagnostic codes (ICD-9) relating to total and partial gastrectomy procedures. Gastric resections for cancer were compared to those for peptic ulcer disease for reference. Patient demographics, comorbidity score, mortality, and hospital characteristics were recorded as covariates.

RESULTS

A significant decrease in annual rates of partial and total gastrectomy was observed from 1993 to 2013 (p < 0.0001). The change in absolute number and percent decline was greater for partial gastrectomy (- 39.3%) than total gastrectomy (- 19%). There was a 34.0% decrease in gastrectomy for cancer in Whites and a 61.2% increase among Hispanic patients over two decades. In-hospital mortality also significantly decreased over the study period (7.7% to 2.7%). Factors associated with lower mortality rates included male sex and treatment at urban teaching hospitals. Analysis of trends revealed that gastrectomy for cancer was performed with increasing frequency at urban teaching hospitals.

CONCLUSIONS

The frequency of major gastric resections in the USA has declined over two decades. Overall, in-hospital mortality rates also have decreased significantly. Declining in-hospital mortality after gastrectomy for cancer is associated with more frequent treatment at urban teaching hospitals.

Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.

AIM

To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.

METHODS

A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.

RESULTS

A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).

CONCLUSION

The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.

Marginal ulcer perforation: a single center experience

PURPOSE

Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP.

METHODS

Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5 years.

RESULTS

Nine patients (2.7 %) presented with MUP. GJ was previously done for either complicated peptic ulcer (n = 4) or for suspected gastric malignancy (n = 5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10 mm. Four patients (44.4 %) had omental patch repair, three (33.3 %) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies.

CONCLUSION

MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.

Randomized clinical trial comparing long-term quality of life for Billroth I versus Roux-en-Y reconstruction after distal gastrectomy for gastric cancer

BACKGROUND

Patients' quality of life (QoL) deteriorates remarkably after gastrectomy. Billroth I reconstruction following distal gastrectomy has the physiological advantage of allowing food to pass through the duodenum. It was hypothesized that Billroth I reconstruction would be superior to Roux-en-Y reconstruction in terms of long-term QoL after distal gastrectomy. This study compared two reconstructions in a multicentre prospective randomized clinical trial to identify the optimal reconstruction procedure.

METHODS

Between January 2009 and September 2010, patients who underwent gastrectomy for gastric cancer were randomized during surgery to Billroth I or Roux-en-Y reconstruction. The primary endpoint was assessment of QoL using the Functional Assessment of Cancer Therapy - Gastric (FACT-Ga) questionnaire 36 months after surgery.

RESULTS

A total of 122 patients were enrolled in the study, 60 to Billroth I and 62 to Roux-en-Y reconstruction. There were no differences between the two groups in terms of postoperative complications or mortality, and no significant differences in FACT-Ga total score (P = 0·496). Symptom scales such as epigastric fullness (heaviness), diarrhoea and fatigue were significantly better in the Billroth I group at 36 months after gastrectomy (heaviness, P = 0·040; diarrhoea, P = 0·046; fatigue, P = 0·029). The rate of weight loss in the third year was lower for patients in the Billroth I group (P = 0·046).

CONCLUSION

The choice of anastomotic reconstruction after distal gastrectomy resulted in no difference in long-term QoL in patients with gastric cancer.

REGISTRATION NUMBER

NCT01065688 (http://www.clinicaltrials.gov).

Gastrojejunostomy without partial gastrectomy to manage duodenal stenosis in a dog

A nine-year-old female Rottweiler with a history of repeated gastrointestinal ulcerations and three previous surgical interventions related to gastrointestinal ulceration presented with symptoms of anorexia and intermittent vomiting. Benign gastric outflow obstruction was diagnosed in the proximal duodenal area. The initial surgical plan was to perform a pylorectomy with gastroduodenostomy (Billroth I procedure), but owing to substantial scar tissue and adhesions in the area a palliative gastrojejunostomy was performed. This procedure provided a bypass for the gastric contents into the proximal jejunum via the new stoma, yet still allowed bile and pancreatic secretions to flow normally via the patent duodenum. The gastrojejunostomy technique was successful in the surgical management of this case, which involved proximal duodenal stricture in the absence of neoplasia. Regular telephonic followup over the next 12 months confirmed that the patient was doing well.

Theodor Billroth: A Surgeon for the 21st Century

This perspective article describes unique aspects of Theodor Billroth's personality and life, which enabled him to succeed and become a leading figure of 19th century medicine. These qualities are discussed with today's developing surgeon in mind.

Sentinel lymph node metastases in cancer: causes, detection and their role in disease progression

Malignant tumors of ectodermal or endodermal origin may metastasize to the sentinel lymph node, the first lymph node encountered by tumor cells that enter lymphatics in the organ of origin. This pathway is enabled by the anatomy of the disease and the causes of metastasis are the result of complex interactions that include mechanical forces within the tumor and host tissues, and molecular factors initiated by tumor cell proliferation, elaboration of cytokines and changes in the tumor microenvironment. Mechanical stresses may influence complex biochemical, genetic and other molecular events and enhance the likelihood of metastasis. This paper summarizes our understanding of interacting molecular, anatomical and mechanical processes which facilitate metastasis to SLNs. Our understanding of these interacting events is based on a combination of clinical and basic science research, in vitro and in vivo, including studies in lymphatic embryology, anatomy, micro-anatomy, pathology, physiology, molecular biology and mechanobiology. The presence of metastatic tumor in the SLN is now more accurately identifiable and, based upon prospective clinical trials, paradigm-changing SLN biopsy has become the standard of clinical practice in breast cancer and melanoma.

Roux-en-Y versus Billroth I reconstruction after distal gastrectomy for gastric cancer: A meta-analysis

AIM: To conduct a meta-analysis to compare Roux-en-Y (R-Y) gastrojejunostomy with gastroduodenal Billroth I (B-I) anastomosis after distal gastrectomy (DG) for gastric cancer.

METHODS: A literature search was performed to identify studies comparing R-Y with B-I after DG for gastric cancer from January 1990 to November 2012 in Medline, Embase, Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed or random effects model. Operative outcomes such as operation time, intraoperative blood loss and postoperative outcomes such as anastomotic leakage and stricture, bile reflux, remnant gastritis, reflux esophagitis, dumping symptoms, delayed gastric emptying and hospital stay were the main outcomes assessed. Meta-analyses were performed using RevMan 5.0 software (Cochrane library).

RESULTS: Four randomized controlled trials (RCTs) and 9 non-randomized observational clinical studies (OCS) involving 478 and 1402 patients respectively were included. Meta-analysis of RCTs revealed that R-Y reconstruction was associated with a reduced bile reflux (OR 0.04, 95%CI: 0.01, 0.14; P < 0.00 001) and remnant gastritis (OR 0.43, 95%CI: 0.28, 0.66; P = 0.0001), however needing a longer operation time (WMD 40.02, 95%CI: 13.93, 66.11; P = 0.003). Meta-analysis of OCS also revealed R-Y reconstruction had a lower incidence of bile reflux (OR 0.21, 95%CI: 0.08, 0.54; P = 0.001), remnant gastritis (OR 0.18, 95%CI: 0.11, 0.29; P < 0.00 001) and reflux esophagitis (OR 0.48, 95%CI: 0.26, 0.89; P = 0.02). However, this reconstruction method was found to be associated with a longer operation time (WMD 31.30, 95%CI: 12.99, 49.60; P = 0.0008).

CONCLUSION: This systematic review point towards some clinical advantages that are rendered by R-Y compared to B-I reconstruction post DG. However there is a need for further adequately powered, well-designed RCTs comparing the same.

Totally laparoscopic distal gastrectomy with D2 lymphadenectomy and Billroth II gastrojejunostomy for gastric cancer: short- and medium-term results of 139 consecutive cases from a single institution

OBJECTIVE

The goal of this study was to investigate the feasibility, safety, and associated 3-year survival outcomes of the totally laparoscopic distal gastrectomy (TLDG) for the treatment of gastric cancer.

METHODS

Herein, we analyzed the clinical data from 139 consecutive patients with gastric cancer who received TLDG at our institution from March of 2007 to March of 2013.

RESULTS

TLDG was successfully carried out in 139 patients; no cases were converted to open surgery. The mean operation time was 228.6 ± 51.0 minutes, mean blood loss was 131.2 ± 85.2 mL, and mean number of dissected lymph nodes was 31.1 ± 9.0. The average time to flatus, time to fluid diet, and length of hospital stay were 3.6 ± 1.1 days, 4.8 ± 1.6 days, and 9.8 ± 4.0 days, respectively. The postoperative morbidity was 10.1%. A total of 135 patients were followed for a subsequent 1-73 months (median, 24.0 months). The 3-year disease-free survival (DFS) and overall survival (OS) rates were 82.3% and 82.9%, respectively. When divided by stage, the 3-year DFS for stage I, II, and III were 100%, 86.2%, and 48.8%, respectively; and the 3-year OS for stage I, II, and III were 98.0%, 92.3%, and 51.6%, respectively.

CONCLUSIONS

In this preliminary report, TLDG was found to be a safe, feasible, and efficacious procedure for the treatment of gastric cancer with encouraging 3-year overall and stage-by-stage survival rates.

Morbidity and mortality results from a prospective randomized controlled trial comparing Billroth I and Roux-en-Y reconstructive procedures after distal gastrectomy for gastric cancer

BACKGROUND

Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed after distal gastrectomy. Which reconstruction procedure is superior remains controversial. We conducted a randomized controlled trial to compare the clinical efficacy of B-I and R-Y.

METHODS

Between August 2005 and December 2008, a total of 332 patients with potentially curable gastric cancer enrolled from 18 institutions were intraoperatively randomized to either the B-I group or the R-Y group. Postoperative morbidity and hospital mortality were recorded prospectively in a fixed format and were compared between these two groups.

RESULTS

The operating time was significantly longer in the R-Y group than in the B-I group (214 vs. 180 minutes, P < 0.0001). Regarding clinical symptoms during the postoperative hospital stay, the incidence of nausea, vomiting, and discontinuance of food intake was significantly higher in the R-Y group than in the B-I group (12.4% vs. 3.7%, P = 0.0027; 8.9% vs. 3.1%, P = 0.022; and 12.4% vs. 4.3%, P = 0.0064, respectively). There was no significant difference in the overall operative morbidity rate between the R-Y and B-I groups (13.6% vs. 8.6%, respectively, P = 0.14). Anastomotic leakage occurred in two patients (1.2%) in the B-I group and in none in the R-Y group; the difference did not reach statistical significance (P = 0.09). Postoperative hospital stay was significantly longer in the R-Y group than in the B-I group (16.4 vs. 14.1 days, P = 0.019).

CONCLUSIONS

We concluded that B-I reconstruction was superior to R-Y reconstruction in terms of perioperative complications.

A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: results from a multi-institutional RCT

BACKGROUND

Both Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed as standard procedures, but it has yet to be determined which reconstruction is better for patients. A randomized prospective phase II trial with body weight loss at 1 year after surgery as a primary endpoint was performed to address this issue. The current report delivers data on the quality of life and degree of postoperative dysfunction, which were the secondary endpoints of this study.

METHODS

Gastric cancer patients who underwent distal gastrectomy were intraoperatively randomized to B-I or R-Y. Postsurgical QOL was evaluated using the EORTC QLQ-C30 and DAUGS 20.

RESULTS

Between August 2005 and December 2008, 332 patients were enrolled in a randomized trial comparing B-I versus R-Y. A mail survey questionnaire sent to 327 patients was completed by 268 (86.2%) of them. EORTC QLQ-C30 scores were as follows: global health status was similar in each group (B-I 73.5 ± 18.8, R-Y 73.2 ± 20.2, p = 0.87). Scores of five functional scales were also similar. Only the dyspnea symptom scale showed superior results for R-Y than for B-I (B-I 13.6 ± 17.9, R-Y 8.6 ± 16.3, p = 0.02). With respect to DAUGS 20, the total score did not differ significantly between the R-Y and B-I groups (24.8 vs. 23.6, p = 0.41). Only reflux symptoms were significantly worse for B-I than for R-Y (0.7 ± 0.6 vs. 0.5 ± 0.6, p = 0.01).

CONCLUSIONS

The B-I and R-Y techniques were generally equivalent in terms of postoperative QOL and dysfunction. Both procedures seem acceptable as standard reconstructions after distal gastrectomy with regard to postoperative QOL and dysfunction.

Reconstruction after gastrectomy: which technique is best?

Several reconstruction techniques are possible after gastrectomy. The best reconstruction is one, that maintains satisfactory nutritional status and quality of life while keeping postoperative morbidity as low as possible. The aim of this study was to describe the different reconstruction techniques that can be proposed after distal and total gastrectomy, heeding to the French guidelines on the use of mechanical sutures in these indications. We then conducted a review of randomized trials dealing with reconstruction techniques after distal and total gastrectomy. After distal gastrectomy, Roux-en-Y reconstruction seems superior to Billroth I and Billroth II reconstructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors. Otherwise, Billroth II should be preferred over Billroth I reconstruction because of lower postoperative morbidity and better oncologic margins. After total gastrectomy, Roux-en-Y reconstruction remains the easiest solution, with satisfactory functional results. Addition of a pouch reservoir after Roux-en-Y reconstruction seems to improve short-term functional outcome after total gastrectomy with better potential for nutritional intake. In the long-term, quality of life seems better mainly in patients with small-resected tumors associated with a good prognosis.

Roux-en-Y reconstruction is superior to billroth I reconstruction in reducing reflux esophagitis after distal gastrectomy: special relationship with the angle of his

BACKGROUND

The aim of the present study was to evaluate the relationship between the angle of His in Roux-en-Y (RY) or Billroth I (BI) reconstruction and reflux esophagitis after distal gastrectomy for gastric cancer.

METHODS

Results for 47 patients undergoing BI reconstruction and 38 patients undergoing RY reconstruction were examined retrospectively. The angle of His and the incidence of reflux esophagitis were determined, and the quality of life (QOL) was evaluated with the Gastrointestinal Symptom Rating Scale (GSRS).

RESULTS

The angle of His was significantly greater in patients who underwent BI compared with RY reconstruction, as well as in patients with reflux esophagitis. Scores for reflux, diarrhea, and total symptoms on the GSRS were significantly better in the RY group than in the BI group.

CONCLUSIONS

The angle of His is an important determinant of reflux esophagitis following distal gastrectomy. The decreased angle of His in patients after RY compared with BI reconstruction may contribute significantly to the reduced incidence of reflux esophagitis and improved QOL in patients who undergo RY reconstruction.

Ludwik Rydygier--contributor to modern surgery

Modern surgery is usually considered to have begun in nineteenth century Europe. One of the most famous contributors to gastric cancer surgery was the Polish surgeon Ludwik Rydygier, born in 1850. He initiated new methods in several fields, such as gastrointestinal surgery, orthopedics, gynecology, and urology. He was the second surgeon in the world to perform an antral resection, which he carried out on November 16, 1880. The patient, a 64-year-old man, suffered from pyloric cancer and died 12 hours after the procedure as a result of postoperative shock. The next pyloric resection was performed by Billroth in Vienna in 1881. In the nineteenth century few gastric resections were performed for peptic ulcer. The first successful antral resection for gastric ulcer penetrating to the pancreas was also performed by Ludwik Rydygier, in 1881. For many years Rydygier advocated resection in the treatment of gastric ulcers, although it was considered too dangerous for benign disease. He eventually proposed four indications for gastric resection: antral cancer, gastric ulcer, perforated gastric ulcer, and bleeding ulcers. Another operation performed for the first time by Ludwik Rydygier was gastroenterostomy, in a patient with a duodenal ulcer. In the following years other types of partial gastric resection and total gastrectomy were introduced. In 1992 the Ludwik Rydygier Association was founded in Krakow to commemorate the achievements of and pay tribute to this great surgeon. The Eighth International Gastric Cancer Congress will take place in 2009 in Krakow, where Ludwik Rydygier built a new surgical clinic in 1889.

Palliative management of gastric cancer

Advanced gastric cancer and its palliative treatment have a long and interesting history. Today, gastric adenocarcinoma is the second leading cause of cancer death worldwide. Unfortunately, many cases are not diagnosed until late stages of disease, which underscores the importance of the palliative treatment of gastric cancer. Palliative care is best defined as the active total care of patients whose disease is not responsive to curative treatment. Although endoscopy is the most useful method for securing the diagnosis of gastric adenocarcinoma, computed tomography may be useful to assess local and distant disease. The main indication for the institution of palliative care is the presence of advanced gastric cancer for which curative treatment is deemed inappropriate. The primary goal of palliative therapy of gastric cancer patients is to improve quality, not necessarily length, of life. Four main modalities of palliative therapy for advanced gastric cancer are discussed: resection, bypass, stenting, and chemotherapy. The choice of modality depends on a variety of factors, including individual patient prognosis and goals, and should be made on case-by-case basis. Future directions include the discovery and development of serum or stool tumor markers aimed at prevention, improving prognostication and stratification, and increasing awareness and education.

Surgical management of complicated ulcer disease

The advent of excellent acid-suppressing medications and the not-so-recent realization of the importance of Helicobacter pylori have markedly altered the physician's management of ulcer-related problems. Although the investigation of acid-peptic disorders helped to launch the modern understanding of abdominal surgery, the majority of operative interventions are now aimed at managing emergent problems that arise from ulcers. There are a waning number of surgeons with extensive experience in the operations that will be described in this report. The global management of patients who suffer from ulcer-related problems will require close cooperation among and between specialties, as well as clear understanding of our respective capabilities and limitations.

Trends and predictors for vagotomy when performing oversew of acute bleeding duodenal ulcer in the United States

BACKGROUND

In the era of Helicobacter pylori treatment, the role of vagotomy in bleeding duodenal ulcers is debatable. National outcomes were evaluated to determine the current surgical treatment and use of vagotomy for bleeding duodenal ulcers.

METHODS

Data from the Nationwide Inpatient Sample (NIS) were used from years 1999 to 2003. Patients were selected using diagnostic codes for acute duodenal ulcer bleed and procedure codes for simple oversew of a bleeding ulcer and vagotomy. Data were analyzed using multiple linear and logistic regression.

RESULTS

Between 1999 and 2003, 100,931 patients with an acute bleeding duodenal ulcer were identified. Over time, there was a decrease in the number of acute bleeding ulcers (p = 0.027) and a decrease in the number of vagotomies (p = 0.027). A high co-morbidity index [odds ratio (OR), 0.60, p = 0.017], operation in the Midwest (OR 0.50, p < 0.001) and operation in the West (OR 0.68, p = 0.034) were predictive of no vagotomy during surgery for a bleeding duodenal ulcer.

CONCLUSIONS

A vagotomy is not commonly performed during surgical treatment of an acute bleeding duodenal ulcer. This variation in practice was not fully explained by patient characteristics. We must seek new evidence to determine the safety of combined medical and surgical management of this clinical problem.

Surgical perspectives in peptic ulcer disease and gastritis

For much of the twentieth century, surgery was frequently the solution for peptic ulcer disease. Our understanding of the pathophysiology of ulcers paralleled the development of potent pharmaceutical therapy. As the surgical world developed parietal cell vagotomy which would minimize the complications of surgery, patients failing medical therapy became rare. Emergent surgery for complicated peptic ulcers has not declined however. The development of proton pump inhibitors and the full understanding of the impact of H pylori has led to a trend towards minimalism in surgical therapy for complicated peptic ulcer disease. In addition to the changes in patient care, these developments have had an impact on the training of surgeons. This article outlines these trends and developments.

Prospective randomized trial comparing Billroth I and Roux-en-Y procedures after distal gastrectomy for gastric carcinoma

To determine the clinical efficacy of Roux-en-Y reconstruction (RY) after distal gastrectomy, we compared postoperative outcomes of patients who underwent RY or conventional Billroth I reconstruction (B-I). A total of 50 patients were prospectively randomized to either B-I or RY reconstruction, and complications, postoperative course, and nutritional status were compared. Bile reflux and inflammation in the remnant stomach and lower esophagus were evaluated by postoperative follow-up endoscopy at 6 months. Operative time and blood loss as well as postoperative nutrition did not show significant differences between the two groups. As anticipated, 5 of 24 patients with RY reconstruction developed gastrojejunal stasis in the early postoperative period, which led to a longer postoperative hospital stay as compared with the B-I group (mean +/- S.D; B-I; 19.0 +/- 6.2, RY; 31.8 +/- 21.7 days) (P < 0.05). Endoscopic examination revealed that the frequency of bile reflux (P < 0.01) and degree of inflammation in the remnant stomach (P < 0.05) were less in the RY group than in the B-I group. However, inflammatory findings in the lower esophagus were observed in 7 (27%) of B-I, and 8 (35%) of the RY group, suggesting that late phase esophagitis was not improved in the RY group. Roux-en-Y reconstruction was effective in preventing duodenogastric reflux and resulting gastritis, but it did not prevent esophagitis. Because RY reconstruction induces the frequent complication of Roux-en-Y stasis, causing longer postoperative hospital stay, this method has limited advantages over B-I anastomosis after distal gastrectomy.

Surgical Management of Ulcer Disease

Surgical management of patients who have acid peptic ulcers requires a firm understanding of the technical options and an even firmer grasp of the anatomic, physiologic, and pathophysiologic relationships of the organs involved. This is a constellation of problems in which the surgeon needs to be far more than a technician. The wealth of information discovered on this subject, from the clinical observations of William Beaumont to the discovery of complex cellular biology and hormonal signaling, is enough to occupy the study of several careers. Although patients who have acid peptic disorders have largely become the primary responsibility of physicians and specialists other than surgeons, when significant complications occur in these patients, it is the surgeon who is called upon to intervene.

Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery

This review describes some of the main intestinal suture and anastomosis techniques up to 1882. The disparity between the great variety of proposed techniques and the paucity of actual clinical application is highlighted. Additionally, the statistical reviews of Rydygier (1881) and Madelung (1882), sources originally written in German and only rarely cited, are compared and analyzed. Historical terminology regarding anastomoses is clarified, and the contribution made by experimental surgery toward the establishment of modern suture technique is discussed. The technique of Philipp Ramdohr (1727) is presented in greater detail.

[Overview of the history of thyroid surgery]

Thyroid gland surgery passed through history from the suggestions for prohibition, during middle of XIX century due to unacceptable mortality even for medieval condition, to highest vel of surgical laser, as W. Halsted sad. First thyroidectomy was done by Albucasis (El Zahrawi) in 925 a.d. and after him by Roger from Salerno. While Pierre-Joseph Dusalt in 1791 has done first operation on thyroid gland than can fulfill todays criteria, Teodor Billroth gave scientific grounds of thyroid surgery. Genius attitude and surgical talent of Theodor Kocher raised thyroid surgery o scientific level, brought surgical skills on the top of surgical art pyramid, and brought him personally to the Nobel Prize in 1909. Every important contribution to development of thyroid surgery gave its giants: Johann von Mikulic, William Halsted, Charles Mayo, George W. Crile and Rank Lahey. Thomas P. Dunhill, F.A. Coller, A.M. Boydena and many others did important contribution, too. Development of thyroid srugery was constant to nowadays, with tendention for multidisciplinary approach in specialized centres. Thyroid surgery in Serbia followed this world trends, in spite of treat problems in the area during history.

Nihilism: a benign denial

Nihilism is the belief that all possible knowledge on a given topic has been amassed and codified. Ranging from benign denial to deliberate attempts at excommunication, nihilism is often encountered in the history of medicine. Eustachius, Columbus, and Sylvius strongly criticized Vesalius and defended the authority of Galen. Riolan fervently rejected Harvey's monumental work on the circulation of blood. Gross stated that no honest and sensible surgeon would ever sanction thyroidectomy. Sandstrom's discovery of the parathyroids was met with silence. Transplantation of parathyroids by Mandl was not appreciated when announced. Aristotle's dictum that the heart cannot withstand serious injury led to Paget's statement that cardiac surgery had reached the limits set by nature, which no new techniques could overcome. The first Billroth I operation was welcomed as, "Hopefully, also the last." Pancreatic surgery was opposed because the organ was of no clinical interest and was impossible for surgeons to reach. Pancreatic transplantation was rejected for many years, despite good results. When Blundell used blood transfusion for postpartum hemorrhage, critics averred that his next exploit would be radical removal of the spleen. Bassini stated that it could be risky to publish more about radical treatment of inguinal hernias. Carcinomas of the lower sigmoid and upper rectum were deemed untreatable because of their inaccessibility. Colostomy during pediatric surgery was rejected many times. Although it is difficult for the human mind to move from a familiar point of view, this propensity should not infect science, thereby impeding advancement.