Totally laparoscopic versus laparoscopy-assisted Billroth-I anastomosis for gastric cancer: a case–control and case-matched study

Between January 2011 and December 2014, 678 patients with primary distal GC underwent laparoscopic radical distal gastrectomy with Billroth-I anastomosis in the Department of Gastric Surgery, Fujian Medical University Union Hospital. Of these patients, three patients with other malignant diseases, 11 patients with T4b GC and 22 patients undergoing TLDG with conventional DSG were excluded. The remaining 642 patients were enrolled in the study. TLDG with MDSG was performed in 158 patients (Group TL), and LADG with a circular anastomosis was performed in 484 patients (Group LA) (Fig. 1). Distal GC was diagnosed preoperatively through analysis of endoscopic biopsy specimens. The pretreatment tumor site, depth of invasion, extent of lymph node (LN) metastasis and metastatic disease were assessed by endoscopy, computed tomography (CT), ultrasonography of the abdomen and/or chest radiography.

All patients voluntarily chose laparoscopic surgery and provided written informed consent prior to surgery. All operations were performed by the same surgeon, who was proficient in laparoscopic surgery, having performed more than 2000 laparoscopic gastrectomy procedures. LN dissection was performed according to the guidelines of the Japanese Gastric Cancer Association [15]. The method of digestive tract reconstruction was according to the patient’s preference.

Laparoscopy-assisted circular anastomosis was conducted according to the traditional method. In our institution, an end-to-side Billroth-I procedure through 5–7 cm upper midline mini-laparotomy was performed. A 28-mm detachable anvil was inserted to the duodenal stump, and a purse string suture was tied over the purse string tying notch of the anvil. Then two Allen clamps were applied to the greater curvature of the stomach at a distance of 5 cm. After the gastric wall was incised between the two clamps, a linear stapler was used to divide the distal stomach and close the lesser curvature. Then a 28-mm circular stapler was inserted through the greater curvature to perform gastroduodenostomy (Fig. 2A). A linear stapler was used to close the greater curvature of the stomach (Fig. 2B).

The MDSG was carried out as described in the literature [11‐13]. For this method, only endoscopic linear staplers were used under a totally laparoscopic approach. In brief, small incisions were made on the greater curvature of the remnant stomach and the posterior side of the duodenum. Following approximation of the posterior walls of the gastric remnant and duodenum, the forks of the stapler were closed and fired, creating a V-shaped anastomosis on the posterior wall (Fig. 2C). Then the instruments of the surgeon and the assistant directly grasped the tissue to efficiently accomplish the involution of the common stab incision. When the common stab incision was closed with the stapler, the blind angle of the duodenum was completely resected at the same time (Fig. 2D). The anastomosis appeared as an inverted T-shape (Fig. 2E).

A retrospective analysis was performed using a prospectively maintained comprehensive database to collect the clinicopathological and follow-up data for all patients. Charlson et al. [16] scoring system was used to evaluate preoperative comorbidity. Postoperative complications were graded according to the Clavien–Dindo scoring system [17]. Clinical and pathological staging were in accordance with the American Joint Committee on Cancer (AJCC) Seventh Edition of Gastric Cancer Tumor, Node, Metastasis (TNM) Staging [18]. The anastomosis was checked for leakage on postoperative days 7–9 by performing an upper gastrointestinal radiograph with diatrizoate meglumine as the contrast medium.

Institutional review board (IRB) of Fujian Medical Union Hospital approved this retrospective study. Written consent was given by the patients for their information to be stored in the hospital database and used for research.

The statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 18.0 for Windows (SPSS Inc., Chicago, IL, USA). One-to-one PSM was performed between the two groups. Multiple-factor logistic regression models were used to calculate the propensity score for each patient; we imposed a caliper of 0.02 of the standard deviation of the logit of the propensity score. Patients in Group TL were individually matched to patients in Group LA according to the nearest neighbor matching principle and the non-replacement principle (i.e., a single case cannot be used multiple times). The measurement data are expressed as the means ± standard deviations. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, whereas continuous variables were analyzed using Student’s t test. To evaluate factors predictive of postoperative morbidity, multivariate analysis was performed using binary logistic multiple regression tests using dummy variables. P values <0.05 were considered statistically significant.

The mean age was 59.7 ± 12.1 years (range 20–87 years), the mean body mass index (BMI) was 22.4 ± 3.2 kg/m² (range 14.7–38.0 kg/m²), and the mean tumor size was 3.4 ± 2.0 cm (range 0.5–12.0 cm) in all 642 patients. Compared with Group LA before PSM, Group TL had a smaller tumor size and a larger proportion of early GC (all P < 0.05). Using one-to-one PSM according to age, gender, BMI, history of abdominal surgery, tumor size, tumor invasion (T), nodal metastasis (N) and TNM stage, 143 pairs from Groups TL and LA were matched (Fig. 3). There were no differences in demographic and pathologic characteristics between groups after PSM (all P < 0.05; Table 1).

All patients successfully underwent laparoscopic radical distal gastrectomy, with only few curable complications occurred and no operation-related death during the perioperative period, and all patients were uneventfully discharged. For all 642 patients, the mean number of harvested LNs was 32.8 ± 10.7 per patient, the mean operation time was 155.1 ± 42.7 min and the media total blood loss was 57.5 ± 40.8 mL. Before PSM, Group TL had more dissected LNs, a longer time to the first fluid diet and a longer postoperative length of stay than Group LA (all P < 0.05). The operation time, total blood loss, time to first flatus and time to soft diet were not significantly different between the two groups (all P > 0.05). After PSM, no difference was found in the intraoperative and postoperative outcomes between the two groups (all P > 0.05) except for the fact that more dissected LNs were obtained in Group LA (P < 0.05; Table 2).

The overall complication rate of all patients before and after PSM was 11.4 and 12.6 %, respectively. Postoperative complications were graded according to the Clavien–Dindo scoring system. The III–IV complications in Group TL were as follows: three patients experienced pulmonary infection and were all treated in the intensive care unit (ICU); two experienced celiac infection and received puncture and drainage with CT guidance; two experienced anastomotic leakage and had a nasojejunal feeding tube placed under X-ray; one experienced abdominal hemorrhage (not including anastomotic bleeding) with exploratory laparotomy treatment to achieve hemostasis; one experienced septicemia and was treated in the ICU; and one experienced inflammatory intestinal obstruction and was treated with endoscopic exploration. The III–IV complications in Group LA were as follows: five patients experienced pulmonary infection, four of whom were treated in the ICU and one of whom received drainage of pleural puncture under local anesthesia; five patients had a nasojejunal feeding tube placed under X-ray, including three anastomotic leakages and two gastric atony diseases; two experienced anastomotic bleeding, one of whom underwent exploratory laparotomy and the one of whom underwent endoscopic exploration to achieve hemostasis; two experienced abdominal hemorrhage (not including anastomotic bleeding), both of whom were treated with exploratory laparotomy to achieve hemostasis; one experienced celiac infection and underwent puncture and drainage by CT guidance; and one experienced an incision infection and underwent re-suturing under general anesthesia. All patients with postoperative complications were cured and discharged. The postoperative complications were similar in the groups before and after PAM (all P > 0.05); anastomosis-related complications were also comparable (all P > 0.05; Table 3).