Laparoscopic surgery is being been increasingly used for the treatment of gastric cancer over the past two decades, especially in East Asian countries such as Japan, Korea, China ,and Taiwan. In general, LGC can be divided into laparoscopy-assisted and pure laparoscopic techniques. With laparoscopy-assisted gastrectomy, lymph-node dissection is performed laparoscopically, but the transection of the stomach and the anastomosis are performed thorough an epigastric mini-laparotomy. Performing the anastomosis in this narrow and restricted space is often difficult, especially on obese patients with thick abdominal walls or on patients with a small remnant stomach.
Although we initially began performing LADG in the hope of overcoming the drawbacks of cumbersome reconstruction, we introduced the use of LDG followed by IC stapled gastroduodenostomy and gastrojejunostomy in 2004. To investigate the feasibility and benefits of IC anastomosis, we compared our experience of using LADG and pure LDG in the current study, using a consecutive series of patients in our institution. We found that the rates for anastomotic complications, including leakage, stenosis, and gastric stasis, were significantly lower for either method of IC mechanical anastomosis (B-I or R-Y) after LDG than for LADG follwed by hand-sewn anastomosis (using any of the three methods). The rate of anastomotic leakage in the IC groups (1.3%) seems to be within the permissible level compared with other accounts using these techniques[15, 16]. Similarly, the rate of of 6.8% for anastomotic leakage after LADG (7.1% for B-I, 11.1% for R-Y and 0% for B-II ) in the current study was comparable with other reports using LADG, with a rate of 7.8% (8.1% (7/87) for B-I and 0% (0/3) for R-Y) reported by Fujiwara et al. and 5.3% (4/76 for B-I with no case for R-Y reconstruction) by Shimizu et al.. The relatively high incidences of anastomotic leakage were possibly associated with the results obtained from initial experience of LADG in each institution.
In the current study, the LADG + EC group had the largest blood loss and longest operating time of the three groups tested. Because patients underwent LADG until May 2004, when we changed our strategy to pure LDG plus IC anastomosis[8, 11], our LADG results might have been subject to some degree of learning-curve effect while we gained experience of laparoscopy-assisted surgical techniques. However, although this dataset does therefore have the drawback of different time periods when each surgical procedure was performed, the reduced blood loss seen with pure LDG may be also reflective of the small wound length required and avoidance of cumbersome anastomosis through a minilaparotomy.
The current study also indicates that pure LDG + B-I resulted in a significantly smaller volume of blood loss and shorter operating time than did pure LDG + R-Y. The consequent reduction in surgical stresses, including operating time and blood loss, and the lower incidence of post-operative complications seemed to be associated with the fact that the LDG + B-I group also had the shortest length of post-operative hospital stay. It should be noted that the mean length of hospital stay in the current study was rather longer than reported elsewhere; however, because the Japanese medical insurance system is structured differently from those in other countries, it is difficult to estimate the correct length of hospital stay based solely on surgical aspects.
In our institution, B-I reconstruction using the delta-shape method with linear staplers was our first choice of reconstruction after LDG, with R-Y reconstruction (also with linear staplers)[8, 12] reserved for selected cases, including those for which tension would be expected on the reconstruction, those with reflux esophagitis or a hiatus hernia, and those with elderly or high-risk patients. As indicated by the numbers of each reconstruction method used (248 B-I reconstructions and 128 R-Y reconstructions in the current consecutive series), B-I was used for the majority of patients who underwent distal gastrectomy.
With regard to post-operative nutritional status, we already confirmed that decreases in body weight and food intake at 12 months post-operatively compared with pre-operative values were significantly less for the LDG + B-I group than for the LDG + R-Y group. In addition, there were fewer subjective reports from patients about their small stomach in the LDG + B-I group than in the LDG + R-Y group. Certainly, bile reflux into the remnant stomach and lower esophagus is one of the drawbacks for B-I reconstruction compared with R-Y reconstruction. It may be closely associated with the development of remnant gastritis, mainly caused by bile reflux. However, as we recently suggested, based on another nationwide survey, the risk of the development of remnant gastric cancer does not appear to be directly associated with the reconstruction method.
The development of our strategy for digestive reconstruction after LDG is indicative of the trend toward IC mechanical reconstruction, which offers advantages in wound length and avoidance of tension through a mini-laparotomy during cumbersome anastomosis. For LDG + R-Y reconstruction, we were able to successfully use IC jejunojejunostomy, which saved a further 20 mm length for the umbilical wound. This also allowed for reduced manipulation of the bowel, and was particularly useful for obese patients, for whom access through a mini-laparotomy can be limited. Reconstruction was performed under continuous laparoscopic guidance, and the disorientating and time-consuming switch to open surgery was thus avoided. In addition, totally IC laparoscopic gastrectomy has been shown to lead to earlier bowel function recovery compared with laparoscopy-assisted and open resections. As indicated by others[15, 23], IC anastomosis is more costly than EC anastomosis, because it requires three to four applications of endoscopic linear stapler cartridges for the anastomosis. We are currently trying to lower the cost by closing the entry hole using an IC hand-sewn technique instead of stapling.