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

Abstract

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.

Introduction

Recently, the occurrence of initial gastric cancer has been rising because of the expansion of mass screening and enhanced investigative methods. As a result, the survival rate of gastric cancer has improved a lot. A study in 2014 revealed that the 5-y survival frequency of dissection 2 (D2) gastrectomy was over 90% in China.¹ Hence, it became necessary to improve postoperative quality of life. As a result, various limited procedures including vagus nerve sparing can be performed.

Laparoscopy-assisted distal gastrectomy (LADG) is a recognized nominally invasive process for the treatment of gastric cancer. LADG has better short-term efficacy compared with open operation,2, 3 such as more resected lymph nodes (LNs), reduced time to flatus, shortened time to liquid diet, shortened time to postoperative hospital stay, higher ambulation, less requirement of analgesic drugs, and less-postoperative nonsurgical site obstacles (cardiopulmonary, urinary, and so forth); moreover, the form of operative method did not impact reappearance in patients with either initial or progressive gastric cancer.⁴ Laparoscopy was used in the operation of the present study, as it can offer an enlarged view and can allow perfect recognition of the nerve branches.

The celiac branch (CB) of the vagus nerve modulates the interdigestive motor movement in the stomach, pylorus, descending duodenum, gallbladder, and sphincter of Oddi, the distal portion of the transverse colon.⁵ These nerves have a noteworthy part in the digestion. As a result, preserving the CB of the vagus nerve in distal gastrectomy (DG) has anatomical basis. Uyama et al.⁶ in addition to Kojima et al.⁷ described that LADG with vagus nerve sparing was useful in stopping gallstone development as well as diarrhea in Roux-en-Y reconstruction (R-Y). Yamada et al.⁸ stated that the occurrence of early dumping syndrome was decreased plus the period to first flatus was earlier while using nerve-preserved DG as opposed to techniques comprising nerve resected. Takiguchi et al.⁹ reported that time to first flatus in the conservation group was also smaller compared with the no conservation group. Vagal nerve preservation gastrectomy is also being introduced in fourth Japanese gastric cancer treatment guidelines because it can reduce postgastrectomy gallstone development, diarrhea, and/or weight loss.¹⁰

The Billroth-Ⅰ (B-Ⅰ) reconstruction has been generally performed because of its methodical ease, with only one anastomotic site in addition to preserving physiological intestinal continuity. And, it has obvious advantages: B-Ⅰ reconstruction has greater short-term operating consequence, and the rate of weight loss is lower.¹¹ In addition, incidences of epigastric fullness, diarrhea, and fatigue were significantly lower in the B-Ⅰ reconstruction group. Nevertheless, gastroesophageal and duodenogastric reflux are well recognized in patients undergoing this kind of restoration after DG and severe gastritis; esophagitis can consequently take place which is the risk factor for gastric stump cancer. Those obstacles extremely distress postoperative quality of life of patients after DG.¹² Endoscopic outcomes established that gastric residue, gastritis, bile reflux, and reflux esophagitis were greater in B-Ⅰ reconstruction than in R-Y (P < 0.001) patients.¹¹ Hence, it is essential to identify the method that can reduce the adverse effect of B-Ⅰ reconstruction.

The influences of CB preservation were evaluated in LADG with R-Y in some studies; however, they still remain controversial in some aspect. Moreover, the efficacy of CB preservation in B-Ⅰ reconstruction has not been clarified. The objective of our study was to reveal short- and long-term efficacy of CB preservation in B-Ⅰ reconstruction after LADG and to identify whether CB preservation can reduce the adverse effects in B-Ⅰ reconstruction.