Comparison of clinical results between the Intra-Abdominal Delta-Shaped Billroth-I Anastomosis (BI) using a linear stapler and Extra-Abdominal BI using a circular stapler in Laparoscopic distal Gastrectomy

Kazuhisa Ehara, MD, PhD, Kazumasa Noda, MD, Yoshiyuki Kawashima, MD, PhD, Tatsuya Yamada, MD, PhD, Takashi Fukuda, MD, Daiji Oka, MD, PhD, Hidetsugu Hanawa, MD, Katsumi Amikura, MD, PhD, Toshimasa Yatsuoka, MD, PhD, Youji Nishimura, MD, PhD, Hirohiko Sakamoto, MD, PhD, Youichi Tanaka, MD, PhD

Gastroenterological Surgery, Saitama Cancer Center

Laparoscopic gastrectomy is increasingly performed in Japan as a minimally invasive surgical procedure for gastric cancer. The intra-abdominal delta-shaped (IA-Delta) gastroduodenostomy using linear staplers, developed by Kanaya et al., is one of the feasible Billroth-I (BI) procedures in laparoscopic distal gastrectomy (LDG). This procedure has made it possible to complete LDG without making an upper abdominal small incision. However, the clinical results of this procedure are still uncertain. In this study, we compared clinical outcomes retrospectively between extra-abdominal (EA) BI using a circular stapler and IA-Delta using a linear stapler.

The data consisted of two hundred and twenty eight patients (pts) who required LDG for early-stage gastric cancer between September 2004 and September 2012. Among the pts, 150 pts underwent EA BI from 2004 to 2010, and 78 pts underwent IA-Delta BI during 2011-2012.
The primary outcomes were operation time (OPT), blood loss (BL), and conversion cases to open laparotomy (Conv). The secondary outcomes were other complications and postoperative hospital stay (PHS).

The overall incidence of early postoperative complications was 7.0%, and the incidence rates were 1.3 % in IA-Delta BI and 10.0 % in EA BI (p=0.0132). The average time of OPT in IA Delta BI and EA BI respectively was 314.2min and 309.8 min and BL 63.0 mls and 85.0 mls, respectively. There was no case of Conv or postoperative death in either procedure.
Regarding EA BI, anastomotic leakage occurred in 4 pts, hemorrhage from anastomosis in 3 pts and stricture of anastomosis in 2 pts. 4 pts showed post-operative gastric stasis. 3 patients each experienced one of wound infection, pneumonia, and wound hernia. These symptoms may be associated with a technical pitfall in EA BI. In IA-Delta BI, only 1 pt showed post-operative gastric stasis, and there were no other complications such as stricture of anastomosis, bile regurgitation, or dumping. Additionally, the PHS was 9.4 days for IA-Delta BI and 15.4 days for EA BI.
IA-Delta BI is superior to EA BI in terms of OPT, BL, other complications and PHS.
This improvement in the outcome may be attributed to two factors. One is that IA-Delta BI is a tension-less procedure, and the other is that it involves no upper abdominal incision wound.
EA BI needs a mini laparotomy, and sometimes it is too small to allow the gastric or duodenal remnant to be handled through this incision for anastomosis. Furthermore, this method often makes injuries to the structures of anastomosis, due to forceful tension.
Moreover, tension at the anastomotic site affects blood flow and wound healing. Incision-less surgery provides less pain, and leads to earlier ambulation, recovery of bowel function, and resumption of oral food intake.

The IA-Delta BI is a safe procedure and shows less morbidity than EA-BI. IA-Delta BI provides better outcomes than EA-BI in terms of QOL after LDG, and we would like to make a presentation about the technical procedure of IA-Delta BI.

Session: Poster Presentation

Program Number: P591

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