Abstract
Background
Delta-shaped anastomosis (DA) has been widely accepted as a standard procedure for intracorporeal Billroth-I reconstruction after laparoscopic distal gastrectomy. We introduced DA in 2010 at our hospital and later developed a modified DA method in which a stapled corner of the duodenal stump was removed simultaneously with closure of an entry hole to reduce postoperative complications.
Methods
The clinical data of 507 patients undergoing laparoscopic distal gastrectomy with DA from October 2010 through December 2018 were retrospectively collected from our in-house database. On the basis of the reviewed data, patients were divided into two groups: the original DA group (org-DA, n = 392) and the modified DA group (mod-DA, n = 115). Surgical outcomes, postoperative nutritional parameters, and endoscopic findings 1 year after surgery were compared between the two groups.
Results
Baseline characteristics were similar between the two groups. Anastomotic stricture occurred in three patients (0.8%) in the org-DA group and one patient (0.9%) in the mod-DA group (P = 0.911). Anastomotic leakage was recorded in five patients (1.3%) in the org-DA group and none of the patients (0%) in the mod-DA group (P = 0.593). One year after surgery, the change in body weight in the org-DA group/mod-DA group was − 8.1%/− 7.0% (P = 0.285), and the change in hemoglobin level was − 5.0%/− 3.9% (P = 0.012). Endoscopic examination at the 1-year follow-up in the mod-DA group showed smaller amounts of food residue (P = 0.008) as well as less residual gastritis (P < 0.001) than in the org-DA group.
Conclusions
The modified DA method can be performed safely with a complication rate comparable with the original DA method. Furthermore, better postoperative function is expected because of its more natural anatomy and physiology resulting from the modified method.
Similar content being viewed by others
References
Katai H, Sasako M, Fukuda H, Nakamura K, Hiki N, Saka M, Yamaue H, Yoshikawa T, Kojima K, Group JGCSS (2010) Safety and feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG 0703). Gastric Cancer 13:238–244
Kim HH, Han SU, Kim MC, Kim W, Lee HJ, Ryu SW, Cho GS, Kim CY, Yang HK, Park DJ, Song KY, Lee SI, Ryu SY, Lee JH, Hyung WJ, Korean Laparoendoscopic Gastrointestinal Surgery Study G (2019) Effect of laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage I gastric cancer: the KLASS-01 randomized clinical trial. JAMA Oncol 5:506–513
Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y (2002) A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery 131:S306–311
Hayashi H, Ochiai T, Shimada H, Gunji Y (2005) Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc 19:1172–1176
Lee JH, Han HS, Lee JH (2005) A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg Endosc 19:168–173
Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, Bae JM (2008) Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg 248:721–727
Kanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, Wada Y, Ohtoshi M (2002) Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg 195:284–287
Huang C, Lin M, Chen Q, Lin J, Zheng C, Li P, Xie J, Wang J, Lu J (2014) A modified delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: a safe and feasible technique. PLoS ONE 9:e102736
Fukunaga T, Ishibashi Y, Oka S, Kanda S, Yube Y, Kohira Y, Matsuo Y, Mori O, Mikami S, Enomoto T, Otsubo T (2018) Augmented rectangle technique for Billroth I anastomosis in totally laparoscopic distal gastrectomy for gastric cancer. Surg Endosc 32:4011–4016
Omori T, Masuzawa T, Akamatsu H, Nishida T (2014) A simple and safe method for Billroth I reconstruction in single-incision laparoscopic gastrectomy using a novel intracorporeal triangular anastomotic technique. J Gastrointest Surg 18:613–616
Brierley J, Gospodarowicz MK, Wittekind C (2017) TNM classification of malignant tumours, 8th edn. Wiley Blackwell, Oxford
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Kubo M, Sasako M, Gotoda T, Ono H, Fujishiro M, Saito D, Sano T, Katai H (2002) Endoscopic evaluation of the remnant stomach after gastrectomy: proposal for a new classification. Gastric Cancer 5:83–89
Kanda Y (2013) Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transpl 48:452–458
Onodera T, Goseki N, Kosaki G (1984) Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi 85:1001–1005
Kumagai K, Shimizu K, Yokoyama N, Aida S, Arima S, Aikou T, Japanese Society for the Study of Postoperative Morbidity after G (2012) Questionnaire survey regarding the current status and controversial issues concerning reconstruction after gastrectomy in Japan. Surg Today 42:411–418
Kinoshita T, Honda M, Matsuki A, Enomoto N, Aizawa M, Nunobe S, Yabusaki H, Abe T, Hiki N (2020) Billroth-I vs Roux-en-Y after distal gastrectomy: a comparison of long-term nutritional status and survival rates from a large-scale multicenter cohort study. Ann Gastroenterol Surg 4:142–150
Sakaguchi M, Hosogi H, Tokoro Y, Yagi D, Shimoike N, Akagawa S, Kanaya S (2020) Functional outcomes of delta-shaped anastomosis after laparoscopic distal gastrectomy. J Gastrointest Surg. https://doi.org/10.1007/s11605-020-04516-7
Kim DG, Choi YY, An JY, Kwon IG, Cho I, Kim YM, Bae JM, Song MG, Noh SH (2013) Comparing the short-term outcomes of totally intracorporeal gastroduodenostomy with extracorporeal gastroduodenostomy after laparoscopic distal gastrectomy for gastric cancer: a single surgeon's experience and a rapid systematic review with meta-analysis. Surg Endosc 27:3153–3161
Huang CM, Lin M, Lin JX, Zheng CH, Li P, Xie JW, Wang JB, Lu J (2014) Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery. World J Gastroenterol 20:10478–10485
Kinoshita T, Shibasaki H, Oshiro T, Ooshiro M, Okazumi S, Katoh R (2011) Comparison of laparoscopy-assisted and total laparoscopic Billroth-I gastrectomy for gastric cancer: a report of short-term outcomes. Surg Endosc 25:1395–1401
Kojima K, Inokuchi M, Kato K, Motoyama K, Sugihara K (2014) Petersen's hernia after laparoscopic distal gastrectomy with Roux-en-Y reconstruction for gastric cancer. Gastric Cancer 17:146–151
Okuno K, Nakagawa M, Kojima K, Kanemoto E, Gokita K, Tanioka T, Inokuchi M (2018) Long-term functional outcomes of Roux-en-Y versus Billroth I reconstructions after laparoscopic distal gastrectomy for gastric cancer: a propensity-score matching analysis. Surg Endosc 32:4465–4471
Ishikawa M, Kitayama J, Kaizaki S, Nakayama H, Ishigami H, Fujii S, Suzuki H, Inoue T, Sako A, Asakage M, Yamashita H, Hatono K, Nagawa H (2005) Prospective randomized trial comparing Billroth I and Roux-en-Y procedures after distal gastrectomy for gastric carcinoma. World J Surg 29:1415–1420 (Discussion 1421)
Zuiki T, Hosoya Y, Kaneda Y, Kurashina K, Saito S, Ui T, Haruta H, Hyodo M, Sata N, Lefor AT, Yasuda Y (2013) Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy. Surg Endosc 27:3683–3689
Kanaya S, Kawamura Y, Kawada H, Iwasaki H, Gomi T, Satoh S, Uyama I (2011) The delta-shaped anastomosis in laparoscopic distal gastrectomy: analysis of the initial 100 consecutive procedures of intracorporeal gastroduodenostomy. Gastric Cancer 14:365–371
Kim BS, Yook JH, Choi YB, Kim KC, Kim MG, Kim TH, Kawada H, Kim BS (2011) Comparison of early outcomes of intracorporeal and extracorporeal gastroduodenostomy after laparoscopic distal gastrectomy for gastric cancer. J Laparoendosc Adv Surg Tech A 21:387–391
Lee SW, Tanigawa N, Nomura E, Tokuhara T, Kawai M, Yokoyama K, Hiramatsu M, Okuda J, Uchiyama K (2012) Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy. World J Surg Oncol 10:267
Noshiro H, Iwasaki H, Miyasaka Y, Kobayashi K, Masatsugu T, Akashi M, Ikeda O (2011) An additional suture secures against pitfalls in delta-shaped gastroduodenostomy after laparoscopic distal gastrectomy. Gastric Cancer 14:385–389
Yanagimoto Y, Omori T, Fujiwara Y, Demura K, Jeong-Ho M, Shinno N, Yamamoto K, Sugimura K, Miyata H, Ushigome H, Takahashi Y, Nishimura J, Yasui M, Asukai K, Yamada D, Wada H, Takahashi H, Ohue M, Yano M, Sakon M (2019) Comparison of the intracorporeal triangular and delta-shaped anastomotic techniques in totally laparoscopic distal gastrectomy for gastric cancer: An analysis with propensity score matching. Surg Endosc 34:2445–2453
Acknowledgements
We thank Andrea Baird, MD, from Edanz Group (https://en-author-services.edanzgroup.com/) for editing a draft of this manuscript. The authors also thank Ms. Tamae Takeuchi for her dedicated support in data collection and language review.
Funding
Drs. Harada, Kinoshita, Sato, Akimoto, Yoshida, and Nishiguchi have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Junichiro Harada, Takahiro Kinoshita, Reo Sato, Eigo Akimoto, Mitsumasa Yoshida, and Yukiko Nishiguchi have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary file1 (MP4 413741 kb)
Rights and permissions
About this article
Cite this article
Harada, J., Kinoshita, T., Sato, R. et al. Delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy for gastric cancer: comparative study of original and modified methods. Surg Endosc 35, 4167–4174 (2021). https://doi.org/10.1007/s00464-020-07896-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-07896-8