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.

Efficacy of Celiac Branch Preservation in Billroth-â Reconstruction After Laparoscopy-Assisted Distal Gastrectomy.

BACKGROUND: The goal of the present retrospective study was to elucidate the efficacy of conserving the celiac branch (CB), which can reduce the adverse reactions of Billroth-Ⅰ (B-Ⅰ) restoration after the laparoscopy-assisted distal gastrectomy (LADG). METHODS: Two hundred thirty-three patients with gastric cancer underwent B-Ⅰ reconstruction after LADG with dissection 2 lymphadenectomy from July 2005 to July 2012 and were monitored for 5 y. The patients were separated into 2 groups: celiac branch preserved (P-CB) group (n = 98) and celiac branch resected (R-CB) group (n = 135). In addition to patient information, tumor features, and surgical details, short-term and long-term variables such as bowel condition, surgical complications, and endoscopy findings were evaluated. RESULTS: In short-term efficacy, the time of first flatus and liquid ingestion were slightly shorter in the P-CB group than in the R-CB group (3.84 ± 0.74 versus 4.38 ± 0.71, P = 0.0001; 5.04 ± 1.07 versus 5.67 ± 1.10, P = 0.0001). For long-term efficacy, the incidences of chronic diarrhea, gastroparesis, residual food, bile reflux, and reflux esophagitis were less in the P-CB group compare with the R-CB group (6.1% versus 22.2%, P = 0.001; 5.1% versus 17.8%, P = 0.004; 4.1% versus 17.8%, P = 0.004; 8.2% versus 17.8%, P = 0.036; 8.2% versus 17.8%, P = 0.036). Other parameters such as postoperative ileus and gallstones had a better efficacy trend in the P-CB group but did not suggestively vary among the groups. CONCLUSIONS: The CB has an imperative part in the gastrointestinal motility, and celiac preservation mainly exerts long-term efficacy in patients who underwent B-I surgery with LADG.

Billroth II reconstruction in gastric cancer surgery: A good option for Western patients.

PURPOSE: The aim of this study is to report the short and long-term results of a cohort of patients who underwent Billroth II (BII) Distal Gastrectomy (DG) for gastric cancer (GC), in a tertiary referral Western center. METHODS: From January 2005 to December 2015, a prospective observational study was conducted in candidate patients to elective gastrectomy for cancer. RESULTS: Among 514 patients observed with GC, a series of 258 patients underwent BII DG for middle/lower third GC. Postoperative mortality and complication rates were 1.5% and 12.4% respectively. The overall and disease-free 5-year survival rates were 78% and 69%, respectively. Young age, lymph nodes retrieved, radicality of resection, and early tumor stages were independent positive prognostic factors at multivariate analysis for 5-year overall survival. Abdominal complications and advanced tumor stages negatively influenced 5-year disease-free survival at multivariate analysis. CONCLUSION: BII provides excellent results in terms of short and long-term prognosis and should be regarded as an acceptable reconstructive option following DG for GC.

Risk factors for duodenal stump leakage after gastrectomy for gastric cancer and management technique of stump leakage.

BACKGROUND/AIMS: The goal of this study was to elucidate the risk factors for duodenal stump leakage after gastrectomy for gastric cancer. In addition, the management of duodenal stump leakage is reviewed. METHODOLOGY: From January 2002 through December 2012, 1,195 patients with gastric cancer who underwent gastric R0 resection were enrolled in this study. The clinicopathologic features, postoperative outcomes (i.e., operation time, hospital stay, surgical procedures, method of duodenal stump closure, retrieved lymph nodes), and the risk factors of duodenal stump leakage were analyzed. RESULTS: Of the 1,195 patients, 13 patients (1.1%) suffered duodenal stump leakage. Most of the patients with duodenal stump leakage were male (92.3%). Nine patients underwent a subtotal gastrectomy with Billroth- II or Roux-en-Y anastomosis; the other four patients underwent a total gastrectomy with a Roux-en-Y anastomosis. There were two mortalities. With univariate and multivariate analysis, age was the most predictable factor for duodenal stump leakage (p= 0.034, p=0.044) CONCLUSIONS: Duodenal stump leakage was affected by the age. For older patients who undergo a radical gastrectomy for gastric cancer, the surgeon must pay meticulous attention to the transection and mobilization of the duodenum in order to prevent duodenal stump leakage.

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy.

BACKGROUND: The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma. MATERIALS AND METHODS: All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up). RESULTS: Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced. CONCLUSIONS: In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.

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.

Comparison of Billroth I and Billroth II reconstructions after laparoscopy-assisted distal gastrectomy: a retrospective analysis of large-scale multicenter results from Korea.

BACKGROUND: Since reconstruction after laparoscopy-assisted distal gastrectomy (LADG) is performed through a small minilaparotomy window, the clinical course and complication rate are influenced by clinical technical expertise and experience. The aim of this study was to compare postoperative complications and survival rates of Billroth I and Billroth II reconstructions after LADG. PATIENTS AND METHODS: We retrospectively collected data from 1,259 patients who underwent LADG performed by ten surgeons at ten hospitals between April 1998 and December 2005. Patients were classified into two groups according to reconstruction method used: the Billroth I group (n=875) and the Billroth II group (n=384). Patient and tumor characteristics, operative details, and postoperative complications were analyzed. RESULTS: Billroth II reconstruction was performed on obese patients (p=0.003) and patients with more advanced tumors (p<0.001). Billroth I reconstruction was performed more frequently in the lower portion of the stomach (p<0.001) and yielded shorter operating times. The postoperative complication rate was 11.4% in the Billroth I group, which was lower than that in the Billroth II group (16.9%) (p=0.011). However, the differences in the major complication rates were not statistically significant (p=0.263). Of the intra-abdominal complications, intraluminal or intraperitoneal bleeding was the most frequent complication in the Billroth I group and duodenal stump leakage was the most frequent in the Billroth II group. The postoperative mortality rate did not show a statistically significant difference. CONCLUSIONS: Both Billroth I and Billroth II techniques are feasible and safe reconstruction methods after LADG for gastric cancer. To reduce major complication rates, surgeons should pay attention to bleeding in Billroth I reconstruction and stump leakage in Billroth II reconstruction.

Technique of antroduodenectomy without ulcer excision as a safe alternative treatment for bleeding chronic duodenal ulcers.

BACKGROUND: The treatment of a bleeding chronic posterior duodenal ulcer, with bleeding recurrence or persistence despite endoscopic therapy, requires surgical treatment and constitutes a challenge for the surgeon; furthermore such chronic ulcers are often wide and sclerotic, so the surgeon needs to avoid the risk of recurrent bleeding if conservative surgery is applied. If radical surgery must be performed, the greater risk involves duodenal leakage, hepatic hilar injury, or pancreatic injury. This study aimed to evaluate the efficacy and complications arising from a surgical procedure, described by Dubois in 1971 (Gastrectomy and gastroduodenal anastomosis for post-bulbar ulcers and peptic ulcers of the second part of the duodenum. J Chir 101:177-186). This operation involves antroduonectomy with gastroduodenal anastomosis. It is similar to a Billroth I gastrectomy but without dissection of the ulcer. MATERIALS AND METHODS: We retrospectively studied the medical data of patients who underwent this procedure for the treatment of bleeding chronic posterior duodenal ulcers during the past 20 years. RESULTS: There were 28 such patients admitted to our institution for emergency surgery, who went on to be treated by the Dubois procedure. Ulcerous disease was efficiently treated without rebleeding or duodenal leakage. The mortality rate was 17%; most deaths resulted from medical failure in older patients suffering from massive bleeding. The rate of medical complications reached 21%. Surgical complications developed in 14% of patients. CONCLUSIONS: The Dubois antroduodenectomy is a safe and effective surgical procedure for the treatment of bleeding chronic duodenal ulcers. The number of fatal outcomes among patients with this condition remains high, particularly in older and vulnerable patients experiencing massive bleeding.

[Centralization on fewer surgeons--an example from gastric surgery]. / Centralisering på den enkelte kirurg--et eksempel fra ventrikelkirurgi.

INTRODUCTION: Previous studies have shown an association between surgical volume and a decreased mortality rate for departments as a whole as well as for individual surgeons. The background for this study was to investigate whether it would be beneficial to centralize gastric surgery, not only in fewer departments but also in fewer hands in the department. MATERIALS AND METHODS: The study was based on the patient records of the 93 patients operated between 1 January 2000 and 1 September 2005. The surgeons were divided into two groups based on whether they had performed more than 15 or less than 5 operations during the period. RESULTS: Of the 93 operations, 3 surgeons performed 80 and 7 surgeons performed the remaining 13 operations. The mortality was significantly increased in patients operated by surgeons with a low operation volume, p = 0.0004. The 12 acute operations were performed as often by a surgeon with low operation volume as by a surgeon with high operation volume. Again, mortality increased when the operation was performed by a surgeon with low operation volume, p = 0.015. CONCLUSION: The results argue for a centralization of gastric resections on a few surgeons and for an organisation of acute surgery so that these procedures are performed by only a few experienced surgeons.

[Comparative assessment of surgical interventions for cancer of the distal part of the stomach].

The author has analyzed the nearest and long-term results of treatment of 260 patients operated on by the Billroth-I method and 220 patients operated on by the Billroth-II method. It was found that after the Billroth-I resection the frequency of disease of the operated stomach was less, the other indices such as postoperative lethality rate, complications, survival up to 10 years, had no substantial difference.

Is pancreaticogastrostomy safer than pancreaticojejunostomy?

BACKGROUND/PURPOSE: Failure of a pancreatic-enteric anastomosis very frequently leads to morbidity and mortality after pancreaticoduodenectomy. Pancreaticojejunostomy or pancreaticogastrostomy is often used after pancreaticoduodenectomy. The many reports on pancreaticogastrostomy support the low rates of anastomotic leakage and mortality compared with pancreaticojejunostomy. METHODS: Between January 1995 and December 2004, 155 pancreaticojejunostomies and 58 pancreaticogastrostomies were performed after pancreatic resection in the Second Department of Surgery of Nagoya University Hospital. Postoperative morbidity and mortality were analyzed. RESULTS: The incidence of pancreatic fistula was similar for the pancreaticojejunostomy (12.2%) and pancreaticogastrostomy (20.7%) groups and the mortality rate was 0% in both groups. CONCLUSIONS: This restrospective clinical study suggested no significant difference in the incidence rate of pancreatic fistula and mortality between pancreaticojejunostomy and pancreaticogastrostomy.

[Formation of invaginational esophago-intestinal anastomosis in reconstructive extirpation of gastric stump].

In 1986-2003 yrs the interventions for cancer of the operated stomach were performed in 32 patients. Reconstructive extirpation of gastric stump (REGS) was conducted in 31 patient, subtotal reresection of gastric stump according to Roux--in 1. Esophago-intestinal anastomosis (EIA) was formed using modified method of K. N. Tsatsanidi. Postoperative mortality was 3.1%. In 1994-2003 yrs, while performing REGS and gastrectomy, EIA was formed in 529 patients. The rate of complicated healing of EIA 1.3%. The insufficiency of the EIA sutures after REGS performance was absent.

Gastric partitioning gastrojejunostomy in unresectable distal gastric cancer patients.

The main purpose of bypass surgery in patients with unresectable distal gastric cancer is to improve their quality of life (QoL). However, the result of conventional gastroenterostomy is dismal including continuous bleeding due to the contact of food material on the tumor surface and early obstruction of the stoma by tumor growth. Developing more effective surgery is warranted to improve the QoL of these patients. Among the 1158 patients with gastric cancer who underwent surgery from March 1993 to July 2002 at Hanyang University Medical Center, 54 (4.7%) had unresectable cancers. Various types of gastrojejunostomy (G-Jstomy), including conventional G-Jstomy (CGJ) (n = 18), antral exclusion G-Jstomy (n = 7), and gastric partitioning G-Jstomy (GPGJ) (n = 17), as well as exploratory laparotomy only (n = 12) were performed in these unresectable cases. In this study, survival and postoperative QoL were compared for the CGJ and GPGJ groups. The median survivals were 120 and 209 days for the CGJ and GPGJ groups, respectively (p = 0.046). The rates of postoperative body weight loss compared to the preoperative weight were 9.3% and 3.1% in the CGJ and GPGJ groups, respectively; the difference showed borderline significance (p = 0.067). The volume of blood transfusion was much less during the postoperative period than during the preoperative period in the GPGJ group but not in the CGJ group. The GPGJ procedure minimized food contact on the tumor surface, which was confirmed by an upper gastrointestinal barium meal series. GPGJ can be recommended as the procedure of choice for bypass surgery in patients with unresectable distal gastric cancer considering their improved survival and postoperative QoL compared to those who underwent CGJ.

[Surgical treatment of gastric and duodenal ulcer disease with chronic duodenal obstruction]. / Khirurgicheskoe lechenie iazvennoi bolezni zheludka i dvenadtsatiperstnoi kishki na fone khronicheskoi duodenal'noi neprokhodimosti.

One hundred and twenty-nine surgeries were performed from 1990 to 2001 for gastric (50) or duodenal (79) ulcers with chronic duodenal obstruction. Resection of 1/2 of the stomach by Bilrot-I was performed in 118 patients, pylorus-saving resection with creation of areflux valve in duodenal bulb--in 5, selective proximal vagotomy with duodenoplasty--in 6 patients. In early postoperative period complications were seen in 10 (10.9%) patients, postoperative lethality was 0.8% (one patient died). There was no insufficiency of anastomotic sutures. Postoperative stay was 11.3 +/- 1.5 days. In remote period after surgery symptoms of chronic pancreatitis was in 2.3% patients, but there were no symptoms of duodenostasis. Roentgenological symptoms of compensated duodenal obstruction were seen in 2 patients operative on for decompensated duodenostasis. These patients had no complaints.

Morbilidad y mortalidad por gastroenteroanastomosis en cáncer gástrico avanzado / Morbility and mortality related to gastroenteroanastomosis for avanced gastric cancer

OBJETIVO: Determinación de la morbilidad y mortalidad post operatorias de la gastroenteroanastomosis en pacientes con cáncer gástrico avanzado. DISEñO DEL ESTUDIO: Revisión retrospectiva de las historias clínicas de todos los pacientes con cáncer gástrico obstructivo distal sometidos a gastroenteroanastomosis en el Instituto de Enfermedades Neoplásicas entre 1980 y 1993. Se analizaron: edad, sexo, hemoglobina, albúmina, riesgo quirúrgico, ascitis, extensión de enfermedad, tiempo operatorio, estancia hospitalaria, morbilidad y moratalidad post operatorias. RESULTADOS: Se realizaron 198 gastroenteroanastomosis con una morbilidad y mortalidad del 20 por ciento y 10 porciento, respectivamente. La neumonía fue la principal causa de morbilidad y mortalidad post operatorias. El riesgo quirúrgico elevado (3-4), la invasión tumoral a órganos vecinos y la presencia de la metástasis peritoneal demostraron ser factores asociados con mayor morbilidad postoperatoria (p<0.05). El único factor de pronóstico de mortalidad postoperatoria fue el riesgo quirúrgico elevado (p<0.01). CONCLUSIONES: Debido a la elevada morbimortalidad post operatoria, la gastroenteroanastomosis no debe realizarse en pacinetes con cáncer gástrico avanzado y riesgo quirúrgico alto

[Morbidity and mortality related to gastroenteroanastomosis in advanced gastric cancer]. / Morbilidad y mortalidad por gastroenteroanastomosis en cancer gástrico avanzado.

OBJECTIVE: Determination of the postoperative morbidity and mortality after gastroenterostomy in patients with unresectable gastric cancer. STUDY DESIGN: Retrospective review of clinical records of all patients with obstructive distal gastric cancer who underwent gastroenterostomy at the Instituto de Enfermedades Neoplásicas between 1980 and 1993. The following factors were analyzed: age, sex, hemoglobin, albumin, preoperative risk, ascites, extent of disease, operative time, hospital stay, morbidity and mortality. RESULTS: 198 gastroenterostomy were done with a morbidity and mortality rates of 20% and 10%, respectively. Pneumonia was the principal cause of postoperative morbidity and mortality. High operative risk, adjacent organ invasion by the tumor and peritoneal metastasis were factors associated with increased postoperative morbidity (p > 0.05). High operative risk was the only prognostic factor for postoperative mortality (p < 0.01). CONCLUSIONS: Because of high postoperative morbidity and mortality, gastroenterostomy should not be done in patients with unresectable gastric cancer and high preoperative risk.

Surgical palliation for pancreatic cancer: will biliary bypass alone suffice?

Because a number of options are available to relieve the obstructed bile duct, stomach or both in patients with irresectable carcinoma of the pancreatic head, palliative surgery for this condition was reviewed retrospectively between 1971 and 1981 at the Royal United Hospital, Bath. One hundred and sixty-five patients underwent a biliary bypass procedure with (n = 37), or without (n = 128) gastric drainage. Thirty patients had a prophylactic gastroenterostomy to avoid gastric outlet obstruction: tumour encroachment made gastroenterostomy essential in seven others. After biliary bypass alone, operative mortality was 14%. After a concomitant gastroenterostomy, mortality was 27% (P less than 0.04). Within a year of biliary bypass alone, there was a 9% incidence of gastric outlet obstruction requiring gastric drainage, with an associated mortality rate of 18%. Survival after biliary bypass or biliary bypass with gastroenterostomy was equal (7-8 months). Except where gastric outlet obstruction is imminent, palliation for irresectable pancreatic head carcinomas should be by biliary bypass alone, because the addition of a gastroenterostomy almost doubles the mortality without any advantage in survival time.

Delayed gastric emptying after palliative gastrojejunostomy for carcinoma of the pancreas.

Fifty-seven patients with carcinoma of the pancreas underwent gastrojejunostomy (GJ) alone or in conjunction with biliary bypass. The mortality rate for GJ alone was 18%; for the combined biliary and duodenal bypass operation it was 5%. Fifteen patients (26%) had delayed gastric emptying (DGE) postoperatively for periods extending from nine to 31 days (average, 16 days); five patients (33%) died. Eight (57%) of 14 patients with preoperative duodenal obstruction and five (42%) of 12 patients with retrocolic GJ experienced DGE postoperatively. Stomal diameter in the patients with DGE averaged 6.5 cm, and 8.4 cm was the average in those without DGE. We conclude that DGE is a frequent and serious problem after GJ for patients with unresectable pancreatic cancer.