Background: Laparoscopy-assisted gastrectomy (LADG) was reported by Kitano et al. in 1994. It is currently one of the option for early gastric cancer treatment. The common reconstruction has been Billroth I method. The roux-en-Y anastomosis is recommended by some surgeons regarding alkaline reflux gastritis, esophagitis, dumping syndrome, and carcinogenesis of the remnant stomach. However, endoscopic retrograde cholangiography (ERC) is sometimes impossible to perform in the conditions of biliary complication or disorder after distal gastrectomy. We developed new reconstruction method which enabale the ERC and can prevent the gastritis of the remnant stomach following LADG.
Surgical technique: After laparoscopic lymph node dissection, jejunum is divided with endoscopic linear stapler at about 30 cm from Treitzfs ligament. The window in the transverse mesocolon was made at the right side of middle colic vessels. The distal side of the divided jejunum was taken cephalad to the transverse colon through this window. Then the reconstruction was performed through the median incision about 6cm long. The anvil head of the circular stapler (SDH 25, Ethicon Endo-Surgery) was inserted into the duodenum and purse-string suture was performed through the minilaparotomy incision. The circular stapler was inserted to the jejunum from its stump. Side to end jejuno-duodenostomy was made. The stump of the jejunum was stapled and closed by linear stapler (Echelon 60mm, Ethicon Endo-Surgery). Small wholes were made in the jejunum and the posterior wall of the stomach. The side to side gastro-jejunostomy was made by linear stapler (Echelon 60mm, Ethicon Endo-Surgery). The whole was hand-sewn and closed. Finally, end to side jejuno-jejnunostomy was performed by hand sewing.
Conclusion: Seven cases underwent reconstruction with this technique. There was a case of intestinal obstruction requiring re-operation. There were no cases with suture failure. Post-operative barium meal study showed barium entered into both duodenum and jejunal loop. Endoscopic biopsy of the remunant stomach revealed less gastritis compared to the Billroth I reconstruction method. Our double tract reconstruction technique after LADG is promising in the points of less gastritis of the remnunt stomach and keep the chance of ERC examination in future.
Program Number: P247