The Development and Future of Digestive Tract Reconstruction after Distal Gastrectomy: A Systemic Review and Meta-Analysis

Reappraisal of optimal reconstruction after distal gastrectomy - a study based on the KLASS-07 database

BACKGROUNDS

This study aimed to compare the incidence of bile reflux, quality of life (QoL), and nutritional status among Billroth II (BII), Billroth II with Braun anastomosis (BII-B), and Roux-en-Y (RY) reconstruction after laparoscopic distal gastrectomy (LDG).

MATERIALS AND METHODS

We reviewed the prospective data of 397 patients from a multicentre database who underwent LDG for gastric cancer between 2018 and 2020 at 20 tertiary teaching hospitals in Korea. Postoperative endoscopic findings, QoL surveys using the European Organization for Research and Treatment of Cancer questionnaire (C30 and STO22), and nutritional and surgical outcomes were compared among groups.

RESULTS

In endoscopic findings, bile reflux was the lowest in the RY group ( n =67), followed by the BII-B ( n =183) and BII groups ( n =147) at 1 year (3.0 vs. 67.8 vs. 84.4%, all P <0.05). The anti-reflux capability of BII-B was statistically better than that of BII, but not as perfect as that of RY. From the perspective of QoL, BII-B was not inferior to RY, but better than BII reconstruction in causing fewer STO22 reflux symptoms at 6 and 12 months. However, only RY caused fewer C30 nausea symptoms than BII at 6 and 12 months, but not BII-B. Nutritional status and morbidities were similar among the three groups, and the operative time did not differ between the BII-B and RY groups.

CONCLUSIONS

BII-B cannot substitute for RY in preventing bile reflux, shortening the operative time, or reducing morbidities. Regarding short-term QoL, BII-B was sufficient to reduce STO22 reflux symptoms but failed to reduce C30 nausea symptoms postoperatively.

Tranditional Roux-en-Y vs Uncut Roux-en-Y in Laparoscopic Distal Gastrectomy: a Randomized Controlled Study

BACKGROUND

Traditional Roux-en-Y may cause Roux-en-Y stasis syndrome (RSS), and Uncut Roux-en-Y was proposed to solve this problem. However, because afferent loop recanalization may occur after surgery, its clinical application remains controversial. The purpose of this study was to compare the long-term outcomes of these two gastrointestinal reconstruction methods.

METHODS

A total of 108 patients who received laparoscopic-assisted distal gastrectomy (LADG) were enrolled; 57 were randomly divided into the Uncut Roux-en-Y (URY) group, and 51 were divided into the Roux-en-Y (RY) group. Patients were followed up for 1 year to evaluate variables, including the following: (1) Assessments for RSS; (2) Preoperative and postoperative Gastrointestinal Symptom Rating Scale (GSRS) scores; (3) Postoperative gastroscopy to assess the occurrence of reflux esophagitis (Los Angeles classification), residual gastritis and bile reflux 1 year after surgery; and (4) Upper gastrointestinal radiography to evaluate whether recanalization occurred in patients in the URY group after surgery.

RESULTS

At 1 year after surgery, a total of 42 patients (73.7%) developed afferent loop recanalization. The incidence of RSS was not different between the two groups (OR, 1.301 [95% CI, 0.482 to 3.509]; P = 0.603P = 0.603). The GSRS score was higher in the URY group (P < 0.001). Postoperative gastroscopy showed that the incidence of bile reflux (P < 0.001) and the grade of residual gastritis (P < 0.001) were significantly higher in the URY group, but the grade of reflux esophagitis was not significantly different (P = 0.447, [95% CI, 0.437 to 0.457]P = 0.397).

CONCLUSIONS

Compared with traditional Roux-en-Y anastomosis, due to the high recanalization rate, the URY group developed more severe gastrointestinal symptoms, the incidence of bile reflux and the grade of residual gastritis increased and the incidence of postoperative RSS was not reduced.

Comparison between laparoscopic uncut Roux-en-Y and Billroth II with Braun anastomosis after distal gastrectomy: A meta-analysis

BACKGROUND

Conventional Billroth II (BII) anastomosis after laparoscopic distal gastrectomy (LDG) for gastric cancer (GC) is associated with bile reflux gastritis, and Roux-en-Y anastomosis is associated with Roux-Y stasis syndrome (RSS). The uncut Roux-en-Y (URY) gastrojejunostomy reduces these complications by blocking the entry of bile and pancreatic juice into the residual stomach and preserving the impulse originating from the duodenum, while BII with Braun (BB) anastomosis reduces the postoperative biliary reflux without RSS. Therefore, the purpose of this study was to compare the efficacy and safety of laparoscopic URY with BB anastomosis in patients with GC who underwent radical distal gastrectomy.

AIM

To evaluate the value of URY in patients with GC.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, Chinese Biomedical Database, and VIP Database for Chinese Technical Periodicals (VIP) were used to search relevant studies published from January 1994 to August 18, 2021. The following databases were also used in our search: Clinicaltrials.gov, Data Archiving and Networked Services, the World Health Organization International Clinical Trials Registry Platform Search Portal (https://www.who.int/clinical-trials-registry-platform/the-ictrp-search-portal), the reference lists of articles and relevant conference proceedings in August 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). We cited high-quality references using its results analysis functionality. The methodological quality of the eligible randomized clinical trials (RCTs) was evaluated using the Cochrane Risk of Bias Tool, and the non-RCTs were evaluated using the Newcastle-Ottawa scale. Statistical analyses were performed using Review Manager (Version 5.4).

RESULTS

Eight studies involving 704 patients were included in this meta-analysis. The incidence of reflux gastritis [odds ratio = 0.07, 95% confidence interval (CI): 0.03-0.19, P < 0.00001] was significantly lower in the URY group than in the BB group. The pH of the postoperative gastric fluid was lower in the URY group than in the BB group at 1 d [mean difference (MD) = -2.03, 95%CI: (-2.73)-(-1.32), P < 0.00001] and 3 d [MD = -2.03, 95%CI: (-2.57)-(-2.03), P < 0.00001] after the operation. However, no significant difference in all the intraoperative outcomes was found between the two groups.

CONCLUSION

This work suggests that URY is superior to BB in gastrointestinal reconstruction after LDG when considering postoperative outcomes.

Uncut Roux-en-Y might reduce the rate of reflux gastritis after radical distal gastrectomy: An evidence mapping from a systematic review

BACKGROUND

To evaluate the efficacy, safety, technical feasibility, and effect of reducing the incidence of reflux gastritis from uncut Roux-en-Y (URY) reconstruction after radical distal gastrectomy (RDG) for gastric cancer.

METHODS

A literature search was conducted in PubMed, EMBASE, Web of Science, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang databases until June 30, 2020, to identify studies comparing URY reconstruction with other gastrointestinal tract reconstruction methods after RDG. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration's risk for bias assessment tool were used to assess the risk of bias. The study was performed using review manager RevMan 5.3.0 software.

RESULTS

A total of 35 original studies (six randomized clinical trials (RCTs) and 29 cohort studies) were included in this analysis with a total of 4100 patients. For reflux gastritis, URY anastomosis was significantly superior to the other four types of anastomoses (Billroth-I (odds ratio (OR) = 0.16 [0.10, 0.27], P < 0.00001); Billroth-II (OR = 0.32 [0.20, 0.51], P < 0.00001); Billroth-II with Braun (OR = 0.14 [0.007, 0.26], P < 0.00001), and Roux-en-Y (OR = 0.59 [0.38, 0.91], P = 0.02)). Furthermore, URY anastomosis was better than Billroth-II with Braun (OR = 0.07, 95%confidence interval (CI): [0.02, 0.28], P = 0.0001) and Billroth-II (OR = 0.14, 95%CI: [0.09, 0.24], P < 0.00001) anastomoses for preventing bile reflux. In addition, for anastomotic leakage, URY anastomosis was significantly superior to Roux-en-Y (OR = 0.34, 95%CI: [0.13, 0.87], P = 0.02) anastomosis, and no statistically significant difference between URY and the other three reconstruction methods was found. The postoperative hospital stay of patients receiving URY anastomosis was substantially shorter than those receiving Billroth-II with Braun (MD: 2.84, 95%CI: [-3.16, -1.80], P < 0.00001), Bollroth-II (MD: 1.23, 95%CI: [-2.10, -0.37], P = 0.005) and Roux-en-Y (MD: 1.98, 95%CI: [-2.17, -1.78], P < 0.00001) anastomoses.

CONCLUSION

URY reconstruction significantly reduce the rate of reflux gastritis after RDG, and it was a more favorable reconstruction method after RDG for its operative simplicity, safety, and reduced postoperative complications especially in Roux-en-Y stasis syndrome. Large sample size cohort studies and well-designed RCTs are needed for further confirmation of our findings.

OTHER

This work was supported by the National Nature Science Foundation of China (No.81871962), Industry-University-Research Innovation Fund in the Ministry of Education of the People's Republic of China (No. 2018A01013) and the Autonomous Intelligent Unmanned System (No. 62088101). This study was registered with PROSPERO (CRD42020200906).

Optimal Reconstruction After Laparoscopic Distal Gastrectomy: A Single-Center Retrospective Study

Objectives

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.

Methods

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.

Results

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).

Conclusions

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.

Continuous Jejunal Pouch and Residual Stomach Anastomosis Combined with Jejunal Lateral Anastomosis: An Improved Method of Gastrointestinal Reconstruction following Distal Gastrectomy

AIM

Currently, there is no optimal digestive tract reconstruction technique well recognized by scholars after distal gastrectomy. A new reconstruction method, which was modified from the classic Roux-en-Y procedure, the continuous jejunal pouch and residual stomach anastomosis combined with jejunal lateral anastomosis (Contin-L), was established. In order to fully clarify the superiority of this procedure, this study has conducted a systematic analysis and prepared a summary of the clinical data of patients who underwent distal gastrectomy for gastric cancer.

METHODS

From June 2013 to March 2016, we enrolled 198 patients with gastric cancer who underwent radical D2 distal gastrectomy. According to the reconstruction methods, these patients were divided into three groups: Contin-L (n = 74), Billroth II (n = 59), and Roux-en-Y (n = 65) groups. The operation time for reconstruction, complications, prognostic nutritional index (PNI), and the Visick grading were analyzed.

RESULTS

Regarding long-term complications, such as reflux gastritis, the Contin-L procedure showed significantly better results than Billroth II (p < 0.0001). Regarding the long-term postoperative nutritional status, such as the PNI and body weight recovery, the Contin-L procedure displayed significantly better results than Billroth II and Roux-en-Y (p < 0.05). Postoperative subjective feelings evaluated by Visick grading were significantly more improved in the Contin-L than in the Billroth II and Roux-en-Y groups (p ≤ 0.01).

CONCLUSIONS

The Contin-L procedure gave full play to the advantages of jejunal continuity, and pouch and lateral anastomoses, which significantly reduced short- and long-term complications, and improved the long-term patient quality of life following the surgical procedure.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND

Single incision plus one port left-side approach (SILS+1/L) totally laparoscopic distal gastrectomy (TLDG) is an emerging technique for the treatment of gastric cancer. Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy: relieving postoperative pain, shortening hospital stay and offering a better cosmetic outcome. Nevertheless, there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y (uncut R-Y) reconstruction.

AIM

To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction (uncut R-Y reconstruction) to treat distal gastric cancer.

METHODS

A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at The Second Hospital of Shandong University. Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler. The clinicopathological characteristics, surgical details, postoperative short-term outcomes, postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.

RESULTS

All SILS+1/L operations were performed by SILS+1/L TLDG successfully. The patient population included 13 men and 8 women with a mean age of 48.2 years (ranged from 40 years to 70 years) and median body mass index of 22.8 kg/m². There were no conversions to open laparotomy, and no other port was placed. The mean operation time was 146 min (ranged 130-180 min), and the estimated mean blood loss was 54 mL (ranged 20-110 mL). The mean duration to flatus and discharge was 2.3 (ranged 1-3.5) and 7.3 (ranged 6-9) d, respectively. The mean number of retrieved lymph nodes was 42 (ranged 30-47). Two patients experienced mild postoperative complications, including surgical site infection (wound at the navel incision) and mild postoperative pancreatic fistula (grade A). Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively. No patients experienced moderate or severe food stasis, alkaline gastritis or bile reflux during the follow-up period. No recanalization of the biliopancreatic limb was found.

CONCLUSION

SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Application of laparoscopic assisted digestive tract reconstruction in patients with gastric cancer: Impact on expression of Cyclin D1 protein

BACKGROUND

At present, the incidence of gastric cancer (GC) in China is high and has been increasing year by year. Since the most effective treatment for GC patients is partial or total resection of the stomach, GC patients often require reconstruction of the digestive tract during surgery. With the continuous development of endoscopic techniques, it is very common to use gastroscopic techniques for reconstruction of the digestive tract in patients with GC. However, it is not very clear whether laparoscopic assisted digestive tract reconstruction can achieve the same efficacy as traditional digestive tract reconstruction.

AIM

To investigate the therapeutic efficacy of laparoscopic assisted gastrointestinal reconstruction in GC patients and the effect on the expression of Cyclin D1 protein.

METHODS

A total of 120 patients with GC who underwent elective laparoscopic total gastrectomy from May 2015 to May 2018 were randomly divided into either a study group or a control group, with 60 cases in each group. The study group underwent ¡°P¡±-shaped jejunal loop with esophagojejunal Roux-en-Y anastomosis for the reconstruction of the digestive tract, and the control group underwent esophagojejunal Roux-en-Y anastomosis. The operation time, intraoperative blood loss, postoperative patient nutritional status, complication rate, and CyclinD1 protein expression were compared between the two groups.

RESULTS

There was no difference in intraoperative blood loss between the two groups (P > 0.05). The operation time and time to recovery of intestinal function were significantly shorter in the study group than in the control group (P < 0.05). Albumin, total protein, and hemoglobin levels in the study group were significantly higher than those of the control group (P < 0.05). The incidence of upper abdominal fullness and dumping syndrome in the study group was significantly lower than that of the control group (P < 0.05), while there was no significant difference in the incidence of diarrhea, reflux esophagitis, anastomotic stenosis, anastomotic bleeding, or pulmonary infection between the two groups (P > 0.05). The expression of Cyclin D1 protein was detected on the 7th day after operation, and all patients had negative results. There was no significant difference between the two groups (P > 0.05).

CONCLUSION

Laparoscopic gastrointestinal reconstruction after total GC resection is beneficial to the recovery of digestive function, improve the postoperative nutritional level of patients, and dose not increase the expression level of Cyclin D1 protein.