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Background. Jejunal pouch reconstruction after total gastrectomy has been demonstrated to ameliorate postgastrectomy symptoms, with the process of adaptation taking several months. In contrast to the short-term effects of pouch reconstruction, there are few reports about the long-term consequences (more than 2 years after surgery). Methods. In this study, 22 patients with jejunal pouch (PRY group) and 12 patients without jejunal pouch (RY group) who survived for more than 2 years without any recurrence and were available for follow-up were compared. Patients in the two groups were compared 2 years after surgery in terms of postgastrectomy symptoms, and improvements in body weight and nutritional parameters. Results. Eating capacity at a single meal compared with that in the pre-illness state was significantly better in the PRY group than in the RY group. The total score on the gastrointestinal symptom rating scale (GSRS) in the PRY group was less than that in the RY group (3.17 vs 5.25). The GSRS score for reflux syndrome in the PRY group was significantly better than that in the RY group. Assessment according to Cuschieri's gradings revealed that the total score in the PRY group was lower than that in the RY group (2.73 vs 5.92). Among the various symptoms examined, the incidence of dietary restriction and that of heartburn were significantly lower in the PRY group. Conclusion. We conclude that, 2 years after total gastrectomy, the pouch reconstruction had alleviated postgastrectomy symptoms to a greater extent than simple Roux-en-Y reconstruction, but the effectiveness could be improved. The long-term effects of pouch reconstruction should be examined more precisely with an adequate and valid scoring system for determining quality of life. [ABSTRACT FROM AUTHOR]

Tc scintigraphy. Surgery revealed a stone incarcerated in the jejunal limb, where the anastomosis had become slightly stenotic. The removed stone was 3.5 cm in diameter and was subsequently demonstrated to be a cholesterol stone by chemical analysis. This report is thought to be the first to describe jejunal limb obstruction caused by a gallstone incarcerated in the jejunal limb after a total gastrectomy in a patient with a history of cholecystectomy. [ABSTRACT FROM AUTHOR]

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Keywords: Gastric cancer; Robotic total gastrectomy; Oeso-jejunal anastomosis; Roux-en-Y reconstruction; Nodes dissection It could be usefull for all surgeons needing to perform a total gastrectomy with nodes dissection. Gastric cancer, Robotic total gastrectomy, Oeso-jejunal anastomosis, Roux-en-Y reconstruction, Nodes dissection. [Extracted from the article]

Roux limb construction is an essential part of several major reconstructive hepatobiliary and upper gastrointestinal surgeries. This can be achieved with a stapling device or suturing. For over two decades, the LigaSure vessel sealing systems (Medtronic, MN, USA) have been in use for omental division, mesenteric transection, and sealing of vessels. We used the LigaSure vessel sealing system with a ForceTriad energy platform (Medtronic) for transection of the bowel during the formation of the Roux limb for a Roux-en-Y reconstruction. Between July 2019 and December 2020, patients who had Roux limb construction as part of a pancreato-enteric anastomosis in surgery for chronic pancreatitis were analysed. The data was reviewed from a prospectively maintained database. Fifteen patients had undergone surgery for chronic pancreatitis. The mentioned technique takes approximately eight minutes to construct a Roux limb. There was no bleeding from the gut ends that had been transected. There was no breach in the bowel's seal. The field was free of enteric contamination. In the post-operative course of these individuals, there was no Roux limb-related morbidity. This procedure is useful because it is cost-effective, time-saving, dependable, and prevents contamination and blood loss. It is also simple to learn and apply., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Gadiyaram et al.)

Hypertrophic pyloric stenosis (HPS) is the most important cause of non-bilious vomiting during infancy and it is usually idiopathic. It is very rare in older children and adolescents, in which gastric outlet obstruction (GOO) is more typically secondary to other conditions. Gastrointestinal malformation are frequently associated with Down syndrome and some of them (especially duodenal abnormalities) can be detected quite late. In infants the standard treatment of HPS is represented by a Ramstedt pyloromyotomy, while in adults a distal gastric resection is more indicated and it is usually associated to a Billroth I or II reconstruction. We present an unusual case of a 12-year-old girl with Down syndrome, diagnosed with late-onset HPS. She came to our attention with periodic non-bilious vomiting and growth delay. She underwent multiple imaging examinations, which highlighted the presence of an HPS. Based on patient's age and the thickness of the pyloric muscle, we decided to perform a partial gastrectomy with a Roux-en-y reconstruction. Patient was discharged on the X day. She is now on follow up, gains weight and presents good conditions. HPS is rare but possible during childhood and adolescence. Diagnosis is usually performed through ultrasounds (US) and upper gastrointestinal radiological series (UGI), but sometimes further examinations are required (abdominal MRI, esophagogastroduodenoscopy). In older children since less invasive techniques are not effective, we have to consider partial gastrectomy. Based on our experience, Roux-en-y reconstruction is a valid option, associated with poor complication and good quality of life. [ABSTRACT FROM AUTHOR]

Afferent loop necrosis after Roux-en-Y cholangiojejunostomy biliary reconstruction is rare. We present the case of a 36-year-old woman with acute necrotic afferent loop obstruction. The peripheral area of the Roux-en-Y limb, including the cholangiojejunostomy portion, was twisted just proximal to the cholangiojejunostomy. Cholangiojejunostomy was completely separated due to necrosis of the Roux-en-Y jejunum. In addition to the case report, we discuss features of cholangiojejunostomy that require special attention. [ABSTRACT FROM AUTHOR]

The use of the double balloon endoscope for ERCP in patients with surgically altered anatomy has shown to be safe and feasible. This technique permits a variety of diagnostic and therapeutic possibilities. A case is presented of a 38-year old male, admitted with jaundice, 8 months after surgery for a malignant liver tumour with construction of a Roux-en-Y hepaticojejunostomy. A stenosis at the site of the biliodigestive anastomosis was diagnosed. Combining double balloon endoscopy with a percutaneous approach in a rendezvous procedure, it was possible to place a self-expandable biliary metal stent. This is the first report of a successful placement of a metallic stent using this technique. [ABSTRACT FROM AUTHOR]

Background/purpose: Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD., Methods: A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model., Results: Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR = 0.49, 95% CI: 0.26-0.95, P = 0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P = 0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay., Conclusions: B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction., (© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: Petersen hernia is a rare but severe complication after gastrectomy, which has been reported by very few studies. This study is dedicated to summarize the clinical characteristics and management of Petersen hernia after gastrectomy in patients with gastric cancer in order to provide reference to clinical practice. Methods: A descriptive case-control study was carried out. All the qualified patients were screened from the database of digestive malignancies in Nanjing Drum Tower Hospital. The inclusion criteria were as follows: Petersen hernia confirmed during operation; previous gastrectomy history due to gastric cancer; complete clinical data. The clinical manifestation, perioperative data and follow-up outcome were summarized. Results: A total of 12 qualified patients were included. They were all male with a mean age of (65.3±8.5) years old, and whose clinical presentation had last for (6~143) hours (median: 21 hours). Common complaints included abdominal pain and bloating. All the patients were admitted to the emergency department. Preoperative CT showed dilatation and effusion of small intestine. Other imaging manifestations included whirlpool sign, target sign, mesenteric retraction or congestion and edema, abdominal and pelvic effusion, etc. Hematological examination showed white blood cell count, ratio of neutrophils, procalcitonin and C-reactive protein were higher than the normal range. The median interval to previous gastrectomy is 20.5 (0.5-55.0) months. The previous gastrectomy of 12 cases included 2 cases of laparoscopic surgery and 10 of laparotomies. Ten cases underwent emergency surgery immediately, and 2 cases underwent surgery after ineffective conservative treatment. Six cases received small bowel restoration without bowel resection, and the other 6 cases received small bowel resection with a mean length of 76 (11~300) cm. Six cases were transferred into ICU with a stay of (2.5±0.8) days. One case deceased at postoperative day 2, due to subtotal small bowel resection, and the other 11 cases survived without grade III or above complication according to Clavien-Dindo classification. The overall postoperative hospitalization was (9.2±3.6) days. During the postoperative follow-up, no acute gastrointestinal symptoms or acute abdomen recurred. Conclusions: Petersen hernia is more common in male, whose onset and progress are rapid and emergent, and prognosis is poor.

Background: What type of reconstruction procedure should be applied is one of the important issues in surgery for gastric cancer. We have several options for reconstruction procedure after distal gastrectomy. The Billroth II and Roux-en-Y reconstruction have a duodenal stump while the Billroth I does not have it, which is the biggest structural difference in these procedures. An increase in intraduodenal pressure due to the formation of duodenum stump occasionally causes severe complication such as duodenal stump leakage; however, a duodenal diverticulum perforation after the Roux-en-Y reconstruction has not yet been reported. Herein, we report two cases of a perforated duodenal diverticulum after gastrectomy with the Roux-en-Y reconstruction. Case presentation: The first case was a 66-year-old man who presented to our hospital with an acute onset right-upper-quadrant abdominal pain. He had undergone laparoscopic distal gastrectomy with the Roux-en-Y reconstruction for the early gastric cancer 15 months before. A large periampullary diverticulum had been detected during the checkup before the gastrectomy. Abdominal contrast-enhanced CT showed a retroperitoneal fluid collection with gas present at the second part of the duodenum. Therefore, a perforated duodenal diverticulum with abdominal abscess was diagnosed, and an emergency laparotomy was performed. Pancreaticoduodenectomy was performed because of severe duodenal inflammation and surrounding tissue damage. The second case was a 52-year-old man who had undergone open distal gastrectomy for locally advanced gastric cancer. Multiple non-ampullary duodenal diverticula had also been identified during the preoperative checkup. On the 2nd postoperative day, he presented with a sudden-onset abdominal pain with peritoneal irritation signs, and intestinal fluid was identified through the intraperitoneal drainage tube placed in a suprapancreatic site during his previous gastrectomy. Therefore, an emergency laparotomy was performed. During laparotomy, a perforated diverticulum at the second part of the duodenum was detected. The perforated duodenum diverticulum was directly sutured with drainage of the retroperitoneal space. Conclusions: It is necessary to recognize that the Roux-en-Y reconstruction after gastrectomy for gastric cancer patients with duodenal diverticulum might cause a perforation of the diverticulum. [ABSTRACT FROM AUTHOR]

Background: Intestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer. Case presentation: A 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma. Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I. Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes. Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation. Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was non-rotation (90°). She was discharged from our hospital without any complications. Conclusion: We encountered a case of adult asymptomatic intestinal malrotation with gastric cancer. Even when encountering such a case during laparoscopic gastrectomy, reviewing CT images carefully to reconsider the anatomical anomalies, and tracing the dissectible layer accurately with adequate countertraction can facilitate safe and successful surgery. [ABSTRACT FROM AUTHOR]

Background: Totally laparoscopic distal gastrectomy is being increasingly performed. However, an optimal procedure to achieve intracorporeal gastrojejunostomy and jejunojejunostomy for Roux-en-Y reconstruction after laparoscopic distal gastrectomy remains to be established. Compared with the simple and preferable circular-stapled Roux-en-Y reconstruction in open gastrectomy, application of intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy of Roux-en-Y reconstruction during laparoscopic distal gastrectomy have been limited (no report of intracorporeal circular-stapled jejunojejunostomy) because of the difficulties of intracorporeal purse-string suture and anvil placement. To address these problems, a simple and safe intraluminal poke technique of universal surgical concept and procedure was introduced and evaluated., Methods: Between March 2018 and August 2018, 24 consecutive patients with gastric cancer underwent totally laparoscopic distal gastrectomy in our hospital. Roux-en-Y reconstruction of intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy with the intraluminal poke technique was performed in all patients. Demographic and clinicopathologic characteristics, perioperative details and postoperative outcomes were analyzed., Results: The mean operative time was 203.6±26.2min, both proximal and distal tumor-free margins were achieved in all patients. The time for anvil placement at stomach and intestine was 5.9±1.3min and 3.9±0.7min, respectively. Intracorporeal gastrojejunostomy and jejunojejunostomy were successively completed following anvil placement with no any anastomosis-related sutures. There were 5 postoperative complications. Morbidities included pancreas fistula (n=1), stasis (n=2), atelectasis (n=1), pneumonia (n=1). These all patients recovered after conservative treatment. No postoperative anastomosis-related complications, such as anastomotic bleeding and leakage, or stenosis occurred during the median follow-up of 6.5 months., Conclusion: The initial results suggest that the technique allowing easy and common anvil placement at stomach and intestine may be a simple, safe, preferable and time-saving procedure to accomplish intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy of Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy as open surgery., (© 2018 Wiley Periodicals, Inc.)

Background/aim: We previously described the safety of distal jejunal pouch with Roux-en-Y reconstruction after total gastrectomy. The present prospective study evaluated its clinical benefit., Patients and Methods: Forty-five patients with gastric cancer were preoperatively assigned to groups who underwent Roux-en-Y reconstruction with jejunal pouch (PRY) (n=23) or without pouch (RY) (n=22). Age, sex, grade of lymph node dissection, splenectomy and mode of laparotomy were analyzed, and body mass index (BMI), volume of food intake at one sitting and blood chemistry (total protein, hemoglobin, iron and cholesterol) were periodically assessed in both groups., Results: Post-surgical mortality and severe morbidity did not occur. Three and four patients in the PRY and RY groups, respectively, died of gastric cancer recurrence during the study. BMI at six months after surgery was significantly higher in the PRY than in the RY group (p<0.05). The percentage of food intake at one year after the procedure was significantly higher in the PRY than in the RY group (p<0.05)., Conclusion: The distal jejunal pouch ameliorated postoperative weight loss and increased food intake. A distal jejunal pouch with PRY reconstruction may confer significant clinical advantages after total gastrectomy. The long-term clinical benefit of this procedure should be evaluated., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Abstract: Background and Objectives: Gastric surgery is a major operation which can cause a related potential deterioration in the patient's quality of life (QoL). This retrospective study investigates the factors which can influence QoL in patients who underwent curative total or subtotal gastrectomy for cancer. Methods: One hundred and three patients were treated via gastrectomy between August 1990 and September 2012: 48 total gastrectomies with Roux-en-Y reconstruction and 55 subtotal resections (among the latter there were 15 Roux-en-Y and 40 Billroth II reconstructions). All patients were interviewed to evaluate their QoL using the EORTC QLQ-C30 and QLQ-STO22 questionnaires. Non-parametric tests were used to analyze the data collected during the interviews considering patient-, tumor- and treatment-related factors. The analysis was corrected for potential confounding factors, in particular considering new onset variables (e.g. comorbidity, treatment and age at time of the interview). Results: QoL correlated negatively with tumor stage and total gastrectomy. In particular, a larger resection for an advanced cancer seems to cause a worse QoL. Furthermore, total gastrectomy is associated with several upper-gastrointestinal tract symptoms. Moreover, after distal resection, patients with a Billroth II reconstruction complain more frequently of dumping syndrome-related symptoms than patients with a Roux-en-Y reconstruction. Conclusions: QoL after gastric surgery for cancer is affected by tumor- and treatment-related factors. In order to improve patients' QoL, subtotal resection with Roux-en-Y reconstruction should be preferred whenever oncologically acceptable. [Copyright &y& Elsevier]

ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.

Background: Practical questionnaires for evaluating duodenogastric reflux following gastrectomy are currently unavailable. The present study evaluated the usefulness of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) questionnaire in the diagnosis of duodenogastric reflux after laparoscopy-assisted distal gastrectomy (LADG), which minimizes the risk of adhesions affecting the gastrointestinal tract. Methods: Subjects in this study comprised 163 patients who had undergone LADG (Billroth-I (B-I), n = 57, Roux-en-Y (R-Y), n = 106). All subjects underwent endoscopy at least 6 mo postoperatively. The FSSG questionnaire was administered a few weeks after endoscopy, and FSSG scores were compared with endoscopic findings. Results: In the R-Y group, FSSG scores were significantly higher in subjects with remnant gastritis than in those without (P = 0.002), and a significant correlation was seen between FSSG scores and bile reflux (P = 0.046). In the B-I group, FSSG scores were significantly higher in subjects with reflux esophagitis than in those without (P = 0.01), but degree of remnant gastritis and residual food did not correlate significantly with FSSG scores. With a cut-off FSSG score of six points, sensitivity and specificity for predicting remnant gastritis in R-Y reconstruction were 71% and 76%, respectively. Conclusion: The FSSG questionnaire is a viable and less invasive alternative to other modalities for evaluating duodenogastric reflux in R-Y reconstruction, but is unsuitable for B-I reconstruction after LADG. [ABSTRACT FROM AUTHOR]

Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)-related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP-related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB-ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB-ERCP and provide several tips for insuring a successful procedure., (© 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Copyright of Langenbecks Archiv fuer Chirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)