As one of the core contents of gastric cancer surgery, the choice of digestive tract
reconstruction method has always been the focus of clinical research in gastric cancer
surgery. There are many alternative methods of digestive tract reconstruction at present, but
there is no absolute superiority among various reconstruction methods. According to the
individual characteristics of patients, the selection of appropriate digestive tract
reconstruction methods should be an important direction in the future research field of
digestive tract reconstruction.
There are many methods of digestive tract reconstruction in distal gastrectomy, including
Billroth-I anastomosis, Billroth-II anastomosis and Roux-en-Y anastomosis. However, the
standard method of reconstruction after distal subtotal gastrectomy does not reach a
consensus. According to Korean Practice Guideline for Gastric Cancer 2018, gastroduodenostomy
and gastrojejunal anastomosis are recommended after distal subtotal gastrectomy for
middle-low gastric cancer, but the priority of different surgical procedures is not
clarified. The conclusion is that there is no significant difference between the Billroth-I,
Billroth-II and Roux-en-Y in postoperative quality of life, nutritional status and long-term
prognosis of patients. Roux-en-Y anastomosis has a lower incidence of bile reflux, but a
higher incidence of delayed gastric emptying compared with Billroth-I and Billroth-II.
Similarly, the Japanese gastric cancer treatment guidelines in 2018 did not specify the
priority of reconstruction methods after distal gastrectomy. In China, the 2022 CSCO
guidelines for the diagnosis and treatment of gastric cancer also did not specify the
priority of reconstruction methods, pointing out that alternative reconstruction methods
include Billroth-I, Billroth-II combine with Braun anastomosis, Roux-en-Y anastomosis, and
jejunal interposition. However, the number of alternative methods indicates that no ideal
reconstruction method has absolute advantages. Therefore, in clinical practice, the specific
choice of digestive tract reconstruction method often needs to be determined by considering
many factors, including the location of the primary tumor, tumor stage, lymph node condition,
anatomical variation and patient's economic situation, etc., which are important factors
affecting the choice of digestive tract reconstruction method.
With the development of laparoscopic technique in recent years, totally laparoscopic
digestive tract reconstruction has become a hot spot in the surgical treatment of gastric
cancer. Laparoscopic digestive tract reconstruction has smaller incision and less trauma,
which is a higher-level laparoscopic surgery pursued by surgeons. However, for patients
undergoing radical gastrectomy for distal gastric cancer, totally laparoscopic distal
gastroduodenal anastomosis is technically difficult. Delta anastomosis was proposed by
Professor Kannaya in Japan in 2002. In this technique, the functional end to end anastomosis
of the posterior wall of the remnant gastroduodenal was completed by using endoscopic linear
staplers under totally laparoscopy, and the suture nails inside the anastomosis were
triangular. It is a widely used functional end to end anastomosis of remnant gastroduodenum
after distal gastrectomy under totally laparoscopic surgery. However, because of the
operation in the duodenum and stomach from broken should meet the requirements of R0
resection of tumor, proper anastomotic tension, and blood supply of free longer duodenal
stump, its restrictive factors, poor controllability, security is still not widely
recognized, it can only be carried out in centers with rich experience in laparoscopic
surgery, and it is more suitable for early cases of gastric Antrum.
In 2016, Professor Changming Huang found that modified Delta anastomosis is safe and feasible
in early gastric cancer, but caution is still needed for locally advanced gastric cancer, its
incidence of postoperative complications and anastomotic leakage was significantly higher
than that of laparoscopic-assisted Billroth-I anastomosis.
In 1995, Oka et al. reported the use of circular stapler for functional end to end
anastomosis of remnant gastroduodenum in open distal gastric cancer radical resection. In
2004, they reported the results of 221 cases, showing that this anastomosis was clinically
safe and reliable. In 2007, Yang et al. in Korea confirmed that functional end to end
anastomosis was safe and feasible in 933 cases of distal gastric cancer, with similar
short-term outcomes compared with Billroth-II anastomosis. However, the clinical staging of
gastric cancer patients in Japan and Korea is mainly early stage, but in China, the clinical
staging of gastric cancer patients is mostly advanced stage.
In conclusion, traditional Billroth-I end-to-side anastomosis and Delta anastomosis require
an additional residual gastric tissue of at least 3cm. In addition, the safe margin of the
broken end of advanced gastric cancer requires a distance of at least 3-5 cm from the tumor,
which often leads to higher anastomotic tension and significantly increases the risk of
anastomotic leakage. Therefore, we propose a new technique for gastrointestinal
reconstruction in laparoscopic distal radical gastrectomy in locally advanced gastric cancer:
Double-Stapling End-to-End Gastroduodenostomy Billroth-I Anastomosis in Laparoscopy-Assisted
Surgery. After previous practice, this anastomotic method can not only ensure a safe surgical
margin, but also retain more residual stomach, so as to effectively solve the problem of
anastomotic tension. It is a safe, simple, physiological and economic anastomotic method.