What is the best reconstruction after totally laparoscopic distal gastrectomy if the delta-shaped gastroduodenostomy cannot be performed?

Totally laparoscopic distal gastrectomy (TLDG) means that all the processes are performed laparoscopically without a mini-laparotomy on the epigastrium for the reconstruction in laparoscopy-assisted distal gastrectomy (LADG) (1). Delta-shaped gastroduodenostomy is a representative type of intracorporeal anastomosis. It has been reported that early postoperative outcomes, such as estimated blood loss, return of bowel function, postoperative pain and hospital stays are significantly improved in TLDG compared with LADG. Furthermore, especially in obese patients, the overall complications rate is significantly lower in TLDG than in LADG because direct visualization by laparoscopy gives a better operation view and minimizes unexpected surgical trauma (2,3). Recently, Kanaya et al. have reported that the short and long-term outcomes of the 100 consecutive patients with a mean follow-up period of 54.9 months. They concluded that the delta-shaped anastomosis is safe, simple, and provides satisfactory postoperative outcomes (4).

However, intracorporeal Billroth-II anastomosis has been rarely reported until now. There is only one report about intracorporeal Billroth-II (5). Intracorporeal Billroth-II anastomosis is usually performed using a linear stapler. When using a linear stapler, theoretically, a stricture in entry hole could be a problem (6).

To solve this problem, in the issue of Journal of Gastrointestinal Surgery (2012;16:738-43), Jianjun Du et al. reported a series of 36 patients with a novel, safe, simple, and time-saving Billroth II anastomosis by only stapling devices after laparoscopic distal gastrectomy. The results grossly appear to be excellent, with good postoperative outcomes and appropriate conduct of the operative procedures. However, we think that this report raises several questions. Firstly, does the entry hole closure by a linear stapler truly cause a stricture? Jianjun De and colleagues assumed that intracorporeal reconstruction of Billroth II was mostly performed by using laparoscopic linear stapler combined with hand-sewn technique. Recently, it is a general trend that the entry hole is usually closed by a linear stapler and this is the most simple and time-saving procedure when intracorporeal gastro-jejunostomy was performed. In experienced hands, it can be finished within 5-10 minutes. The reasons for the hand-sewing closure of the entry hole are a problem of cost and concern for stricture of the efferent loop. Leaving the expense aside, this kind of stricture problem could be avoided if the entry hole is made on the afferent loop side (7). And also with the proper stapling technique, the amount of sacrificed tissue after linear stapling could be even lower than that of hand-sewing manner, which means a proper linear stapling technique do not cause a stricture in the jejunum.

Secondly, Billroth II reconstruction is not a recommendable method in the current situation. There is much concern about gastric remnant carcinoma and worse postoperative quality of life due to alkaline reflux gastritis (8), although Billroth II gastro-jejunostomy is still widely used as a reconstruction after distal gastrectomy. In this point of view, Roux-en Y type reconstruction has been reported as a better option with the advantage of less bile reflux into the remnant stomach or reflux esophagitis than Billroth II anastomosis (9). And also Roux-en Y reconstruction is thought to be more natural and simple way to make gastro-jejunostomy using a circular stapler.

Thus, what is the best reconstruction after totally laparoscopic distal gastrectomy if the delta-shaped gastroduodenostomy cannot be performed? We cautiously recommend Roux-en Y gastro-jejunostomy rather than Billroth II anastomosis. It has been reported that Roux-en Y anastomosis is superior to Billroth II anastomosis in terms of frequency of bile reflux. Furthermore, it can be performed without concern about the stricture in the common entry hole. However, we need more solid evidence from further clinical trials to determine the best anastomosis after TLDG.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

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