Blogs
FAQ
Journal of Pioneering Medical Sciences
Open Access
0.25
Impact Factor (WoS)
Submit Article
Background: Laparoscopic gastrectomy with Roux-en-Y reconstruction is a widely accepted procedure for gastric cancer. However, evidence on its short-term outcomes in the Indian population remains limited. Methods: This prospective observational study was conducted in the Department of General Surgery, Government Medical College, Srinagar, over 18 months. Patients with operable gastric carcinoma undergoing laparoscopic gastrectomy with Roux-en-Y reconstruction were assessed for intraoperative parameters, complications, lymph node yield and short-term postoperative outcomes. Results: Thirty-one patients were included (mean age 63 years; M:F = 3:1). Total gastrectomy and D2 lymphadenectomy were performed in most patients. The antecolic approach had a shorter operative time than the retrocolic approach (p<0.001). The mean blood loss was minimal and the overall complication rate was 16.1%, with no perioperative mortality. The mean hospital stay was 6-7 days and no cases of Roux limb stasis were observed. Conclusion: Laparoscopic Roux-en-Y reconstruction after gastrectomy is safe, feasible and associated with minimal morbidity and satisfactory short-term oncological outcomes.
It is the 5th most common cancer in the world which accounts for 4.8% of total cancer population worldwide. It is the 5th leading cause of Cancer Death in the world [1]. It is the 7th most common cancer in India [2]. Predominantly affects Men. It is the most common cancer in Jammu and Kashmir [3] along with CA Esophagus. Overall survival improves significantly with curative R0 resection.
While worldwide the standard technique is via a laparotomy, minimally invasive techniques, including endoscopic resection for very early tumors and laparoscopy, have proven effective. First Laparoscopic Gastrectomy with Billroth II reconstruction for Gastric Ulcer was carried out by Goh et al [4] in 1992. Laparoscopic Distal Gastrectomy for early Gastric cancer was first developed in Japan and was first reported by Kitano et al. [5] in 1994. After this preliminary result, the technique has spread in Asia with several case series confirming its safety and feasibility. Laparoscopic approach has been extended to include even Locally advanced Gastric cancers. Laparoscopic Gastric resections have advantages like any other Laparoscopic procedure like reduced pain, shorter hospitalization and improved Quality of Life. Long term Outcomes are comparable to Conventional Open Gastrectomies.
The extent of Lymphadenectomy associated with Gastrectomies have been controversial. Most patients with carcinoma stomach presents with Nodal metastasis at the time of Presentation. In these patients Lymphadenectomy improves the Staging accuracy and is the Standard of care. Current NCCN guidelines recommend D2 Lymphadenectomy in the “hands of experienced surgeons with expertise in the field, at tertiary centers where Gastrectomies are often performed.” The Choice of Specific Reconstruction method remains unclear. Surgeons must understand the merits and demerits of every anastomotic device and procedure. A reasonable reconstruction procedure should be selected to improve the quality of Life Post Operatively by considering the following factors:
Safety (anastomosis with sufficient blood supply and free tension), Efficiency (Simple and Time Saving), Minimal Invasion (Less Blood Loss), Stability (surgeon's preference and experience) and Quality of Life (function preservation, if possible, reflux prevention and nutrition). The anastomosis of the gastric remnant to a defunctionalized jejunal limb in a RY reduces biliopancreatic reflux and abolishes the Afferent Loop Syndrome seen in Billroth-II.
RY reconstruction can reduce the incidence of food residues, Reflux Esophagitis, Remnant Gastritis and bile reflux in follow-up endoscopic findings and has a favourable long-term outcome than other techniques like Billroth-I and Billroth-II Reconstruction. Roux-en-Y reconstruction is a more complicated procedure than Billroth-I or Billroth-II because it involves two anastomoses [6]. Therefore, the operation time and anastomosis time were significantly longer for Roux-en-Y than for Billroth-1 and multiple anastomotic lines could increase the probability of anastomotic leakage.
RY reconstruction can be done Antecolic and Retrocolic. The choice between them depends on factors like Surgeon preference, patient anatomy and Risk of complications. Antecolic RY is technically easier, faster and carries Low risk of Internal Hernia and has disadvantages like delayed Gastric emptying. Retrocolic RY may improve gastric emptying but it is technically more complex, time consuming and there is higher risk of Internal Hernia because of the Mesocolic defect. Roux stasis syndrome [7] may occur in up to 30% of patients after Roux-en-Y gastroenterostomy and results from functional obstruction due to disruption of the normal propagation of pacesetter potentials in the Roux limb from the proximal duodenum as well as altered motility in the gastric remnant. Despite international evidence supporting laparoscopic gastrectomy with Roux-en-Y reconstruction, data from Indian centers remain scarce. Variations in patient profile, surgical expertise and resource availability warrant region-specific evaluation. This study was conducted to assess the short-term outcomes, safety and feasibility of laparoscopic Roux-en-Y reconstruction after gastrectomy in an Indian tertiary care setting.
Aim
The present study was aimed to Study the Safety and Feasibility of Laparoscopic Roux-en-Y Reconstruction after Laparoscopic Gastrectomy for Gastric Cancers.
Objectives
Primary Objectives
Secondary Objectives
After obtaining approval from the Institutional Ethics Committee, the study was conducted in the Department of General Surgery, Government Medical College, Srinagar, over a period of 18 months, with patients followed up for 6 months postoperatively.
The study was approved by the Institutional Ethics Committee (Ref. No. GMC/IEC/2022/74) and written informed consent was obtained from all participants prior to inclusion in the study.
Study Design
Prospective observational study.
This was a prospective observational study. All patients diagnosed with operable gastric carcinoma and fulfilling the inclusion criteria during the study period were consecutively enrolled. A convenience sampling approach was used, as all eligible patients undergoing laparoscopic gastrectomy with Roux-en-Y reconstruction at the institution were included.
A total of 31 patients were included in the study. The sample size was determined by the number of eligible cases presenting during the 18-month study period, considering the low incidence of operable gastric cancer and institutional case load. Although not based on a formal power calculation, this sample was deemed adequate for preliminary evaluation of short-term outcomes and feasibility in the regional population.
Data were entered and analyzed using IBM SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY, USA). Data normality was assessed using the Shapiro-Wilk test. Continuous variables were expressed as Mean±Standard deviation (SD), while categorical variables were presented as frequencies and percentages. The Mann-Whitney U test was used for comparison between groups, with a p-value <0.05 considered statistically significant. The Mann-Whitney U test was used for comparison between groups, with a p-value <0.05 considered statistically significant. Follow-up data were analyzed descriptively, focusing on clinical outcomes and disease-free survival at 6 months.
Inclusion Criteria
Exclusion Criteria
All the patients who met inclusion criteria were enrolled for the study. After admission detailed history and clinical examination were done in all the patients. Patient’s data including Gender, Age, Clinical Presentation, Tumour location and histopathological type and grade of tumour were noted. All the Data obtained were recorded in the proforma and were subjected to relevant statistical analysis.
Surgical Procedure
All patients were preoperatively optimized with correction of electrolyte imbalances and nutritional deficiencies. Standard preoperative preparation included overnight fasting, Ryle’s tube insertion with gastric lavage and bowel preparation using a polyethylene glycol-based solution 24-48 hours prior to surgery. A single prophylactic dose of intravenous antibiotic was administered one hour before induction of anesthesia.
The procedure was standardized for all patients undergoing laparoscopic Roux-en-Y reconstruction following laparoscopic gastrectomy. Under general anesthesia, patients were placed in the French position and pneumoperitoneum was established using a closed Veress needle technique. Port placement followed a uniform pattern to facilitate optimal exposure and ergonomics for the operating and assisting surgeons. A diagnostic laparoscopy was performed in all cases to rule out metastasis and confirm resectability.
Depending on tumor location, either total or distal laparoscopic gastrectomy was performed, followed by D2 lymphadenectomy as per oncological principles. Reconstruction was carried out using the Roux-en-Y technique, through either an antecolic or retrocolic route based on intraoperative assessment and surgeon preference.
Steps
The Procedure was Standardized for all the patients Undergoing Laparoscopic Roux-en-Y Reconstruction after Laparoscopic gastrectomy.
Port Placement
The patient was placed in the French position, with arms tucked by the side of the patient. The monitor was placed on the Left shoulder of the patient. General anaesthesia was administered and few of them were given epidural anaesthesia. The operating surgeon comes in between the legs of the patient and the camera surgeon would shift from right to left side as per the convenience of dissection by the operating surgeon. The assistant holding the liver would come from the right side. The scrub nurse would come from the right side of the surgeon. The pneumo-peritoneum was created with a closed technique using a Veress needle at the base of the umbilicus. The 10 mm optical port was placed through the umbilicus for distal gastric tumours and 2-3 cm above and to the left of umbilicus for tumours located in the incisura and body of stomach.
The two working ports were placed, one in the right upper quadrant 10/ 12 mm and other working port was placed in the left upper quadrant 10/12 mm. A 5 mm retraction port was made in the epigastric region and another accessory port was made below the right working port of the surgeon (5 mm), slightly head up position was given to the patient. Diagnostic laparoscopy was done as a standard protocol in all patients to stage the tumour (liver or peritoneal metastasis, ascites) and plan the surgical management. The status of the tumour, the site of tumour and its fixity to the underlying structures were confirmed. For the tumours placed distally in the antrum, pylorus and incisura, partial gastrectomy was performed. Tumours in the body or higher a total laparoscopic gastrectomy was performed.
The following steps of gastrectomy were performed in a step wise manner:
Roux-en-Y Reconstruction
The Steps involving Roux-en-Y Reconstruction are:
The cut end of the esophagus which is stapled by the linear stapler held by one/two stay sutures and fixed to the crura and to be anastomosed to the Roux loop in a side-to-side fashion. We identify the ligament of Treitz and follow the bowel 25-30 cm from ligament of Treitz, the bowel is cut by a linear stapler into proximal Biliopancreatic limb and distal Roux limb. The mesentery is cut so that loop of the jejunal bowel selected will be freely mobile and able to reach the site of future gastro/esophageal-jejunal anastomosis. The anastomosis between gastric/esophagus and jejunum is performed by linear stapler. The Ryles tube is pushed by the anaesthetists and negotiated from the esophagus in to the Roux limb; the otomy is repaired by 2-0, 15 cm V loc. 35-40 cm down to this gastric/esophago-jejunal anastomosis, Jejuno-jejunostomy is performed in a side-to-side pattern by using linear stapler and otomy is closed by 2-0 15 cm V-Loc (Figure 1-6).
Figure 1: CECT Showing Circumferential enhancing Growth involving Antropyloric Region with extension along Lesser Curvature of Stomach. (Axial Plane)
Figure 2: CECT Showing Hypo enhancing Thickening involving Mid Body of Stomach with Situs Inversus Totalis. (Axial Plane)
Figure 3: Operative Images of Total Gastrectomy with Ante-Colic Roux-En-Y Reconstruction in a Patient with Situs Inversus Totalis
Figure 4(a-r): (a) Diagnostic Laparoscopy, (b) Division of Gastrocolic Ligament and Omentum, (c) Tumour in Mid Body (posterior wall), (d) Division of Short Gastrics and Gastrophrenic Ligaments, (e) Division of Lesser Omentum, (f) Mobilisation of Distal Esophagus, (g) Resection at D1 using Endo Linear Stapler, (h) Image Showing Duodenal Stump and Pancreas after Distal Resection of Stomach, (i) Stay Sutures at Crura of Diaphragm to prevent Retraction of Distal Esophagus into Thorax, (j) Resection at Distal Esophagus using Endo Linear Stapler, (k) Image showing DJ Flexure to begin tracing of Jejunum, (l) Resection of Jejunum 25-30 cm from DJ Flexure with Tattooing of Proximal (Biliopancreatic) Limb using Endoclips, (m) Division of Mesentery of Distal (Roux) Limb for Adequate Mobilisation, (n) Performing Jejunojejunostomy approx. 25-35 cm distal to Roux Limb, (o) Closing Otomy of Jejunojejunostomy using V-Loc Suture, (p) Performing Esophago-Jejunostomy, (q) Introducing Ryles Tube across Esophago-Jejunostomy and (r) Closing Otomy of Esophago-Jejunostomy using V-Loc Sutures
Download PDF
Download XML
Download Full Text
