Laparoscopic Stomach-Partitioning Gastrojejunostomy with Reduced-Port Techniques for Unresectable Distal Gastric Cancer

Introduction

An increasing interest in medical checkups has led to an early detection of gastric cancer. On the other hand, recent progress in chemotherapy and the development of molecular-targeted drugs have remarkably improved the survival of patients with advanced gastric cancer. However, patients with an unresectable gastric cancer often experience pyloric stenosis or bleeding from the tumors, which may lead to deterioration of their quality of life (QOL). ¹ Patients with such a locally advanced gastric cancer, distant metastases, or peritoneal dissemination may undergo either of two types of nonradical operation: reduction surgery or palliative operation. Reduction surgery is designed to reduce the tumor burden by gastric resection and to delay the onset of unpleasant symptoms or death, whereas a palliative operation may involve procedures such as gastrojejunostomy and focus on alleviating the clinical symptoms. ² Recently, we have often encountered gastric cancer patients who had a gastric outlet obstruction and successfully underwent a radical resection following a bypass operation and subsequent oral anticancer chemotherapy. This fact represents the great significance of a bypass operation in cancer treatment. ³

The recent development of single-port laparoscopic surgery has evidently made it possible to perform bypass operations less invasively. ⁴ Providing less invasive operations will allow patients to resume oral intake and to be discharged or receive chemotherapy immediately after surgery. The following report is about a laparoscopic stomach-partitioning gastrojejunostomy with reduced-port techniques for unresectable distal gastric cancers.

Materials and Methods

Surgical technique

The patient was placed in the supine position with legs apart, under a combination of epidural and general anesthesia. A 2.5-cm vertical intraumbilical incision was made, and EZ Access (Hakko Co., Ltd., Tokyo, Japan) was placed. An additional 5-mm trocar was inserted in the right upper abdomen for the insertion of forceps held by the left hand of the operator. In EZ Access, a 12-mm trocar for a camera, a 12-mm trocar for use by the operator's right hand, and a 5-mm trocar for use by the assistant were placed. Intraabdominal pressure was maintained constantly at 8 mm Hg.

The whole peritoneal cavity was carefully observed first. Then the operators checked for peritoneal dissemination and liver metastasis. Peritoneal cytology was performed on local areas near the gastric tumor and the pouch of Douglas. The bursa omentalis was released, and the invasion of the tumor into the pancreas or the hepatoduodenal ligament and other factors representing the degree of local progression of the tumor should be evaluated prior to making a final decision on whether a radical resection could be indicated.

Gastrojejunostomy was performed on the oral side toward the tumor of the stomach: at least 3 cm away from the tumor for macroscopic localized types (Borrmann I and II) or 5 cm away for infiltrative types (Borrmann III and IV). Because the jejunum was anastomosed to the greater curvature of the stomach similar to a side-to-side anastomosis, the marginal branches of the gastroepiploic artery and vein were dissected along the greater curvature by nearly 60 mm wide using an ultrasonically activated scalpel device (USAD) (Sono-Surg X™; Olympus, Tokyo).

An jejunal loop, a nearly 20-cm part of the jejunum from the ligament of Treitz, was ascended antecolically and anastomosed to the greater curvature of the stomach. The USAD was used to divide the mesentery and marginal peripheral blood vessels of the elevated jejunum. A small entry hole was made on both the antimesenteric side of the jejunum and the greater curvature of the stomach with the USAD. An endoscopic linear stapler cartridge fork (EndoGIA Universal™ 60-3.5; Covidien, Mansfield, MA) was inserted into the small enterotomy. Then the jejunal loop was brought up to the stomach by using the stapling device, and the other fork of the stapler was inserted into the small gastrotomy. An antiperistaltic side-to-side gastrojejunostomy was created by firing the linear stapler (Figs. 1a and 2). The anastomotic line was checked for hemostasis through the common entry hole. Any bleeding or oozing was controlled by bipolar coagulation (Fig. 3). Another endoscopic linear stapler was inserted into the tear in the jejunal mesentery, and the jejunal loop together with the stomach was dissected just proximal to the common entry hole so that a functional end-to-end gastrojejunostomy was completed (Figs. 1b and c and 4). At this time, the stomach was partitioned using an additional stapler from the greater curvature toward the lesser curvature to leave a 2-cm-wide passage in the lesser curvature. When the remaining part of the lesser curvature of the stomach was too large after a single firing of the linear stapler, an additional linear stapler would be used for the partition of the stomach (Figs. 1d and e and 5). Finally, a linear stapler was fired to close the distal portion of the common entry hole (Figs. 1f and 6) so that the intracorporeal stomach-partitioning side-to-side antiperistaltic gastrojejunostomy was completed (Figs. 1g and 7).

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FIG. 1.

Schematic outline of the stomach-partitioning gastrojejunostomy. (a) The side-to-side gastrojejunostomy was created to the greater curvature by firing the linear stapler. The marginal branches of the gastroepiploic artery and vein were dissected along the greater curvature. (b) The linear stapler was applied. (c) The end-to-end gastrojejunostomy was completed. (d) The stomach was partitioned using an additional linear stapler. (e) The remaining part of the lesser curvature was 2 cm wide. (f) The common entry hole was closed using the linear stapler. (g) The stomach-partitioning gastrojejunostomy was completed.

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FIG. 2.

An endoscopic linear stapler cartridge fork was inserted into the small entry hole created on the elevated jejunal wall. The other linear stapler fork was introduced into the small gastrotomy. The antiperistaltic side-to-side gastrojejunostomy was formed by firing the linear stapler.

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FIG. 3.

The anastomosis was checked for any bleeding through the common entry hole.

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FIG. 4.

The jejunal loop together with the stomach was dissected just proximal to the common entry hole.

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FIG. 5.

An additional linear stapler would be used to partition the stomach, leaving a 2-cm-wide passage in the lesser curvature.

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FIG. 6.

Another linear stapler was fired to close the distal portion of the common entry hole.

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FIG. 7.

The laparoscopic stomach-partitioning gastrojejunostomy resembling an antiperistaltic side-to-side anastomosis was completed.

Subsequently, a side-to-side or an end-to-side jejunojejunostomy was performed 30 cm distal to the gastrojejunostomy by the conventional method with a linear stapler, intracorporeally, or by the extracorporeal hand-sewing technique through a navel EZ Access port wound to save staplers, and the Roux-en-Y anastomosis was completed.

Results

The procedure was completed in 7 patients (five men and two women). The patients' mean age was 69 years old (range, 58–82 years old). Mean operative time was 85 minutes (range, 63–103 minutes). Mean intraoperative blood loss was 3 mL (range, 0–10 mL).

All patients were able to tolerate oral intake on the day following surgery. Neither anastomotic leakages nor anastomotic strictures were observed. The patients' mean hospitalization period was 24 days (range, 18–32 days); the length of hospitalization was slightly prolonged because of their requirements for pain control.

Discussion

A growing awareness of health care and recent advances in image-enhanced endoscopy, such as narrow-band imaging and flexible spectral imaging color enhancement, have led to a dramatic improvement in the management of patients with gastric cancer. These advances have made it possible for us to detect early gastric cancers that can be treated by endoscopy. However, a large number of patients with gastric cancer still remain to be diagnosed at highly advanced stages and resign from radical operation. Surgical management for such patients includes reduction and palliative surgeries. ²

Reduction surgery is indicated, in the form of gastrectomy, for patients with nonradical factors such as liver metastasis and peritoneal dissemination but without tumor-associated symptoms such as bleeding, stenosis, or pain. Reduction of the tumor mass may enhance the antitumor effects of the prescribed anticancer drugs and prolong the survival. However, reduction surgery lacks a high level of evidence and requires further study.^5,6 Unlike reduction surgery, palliative operations do not aim to prolong the patient's survival. Rather, they are designed to improve the patient's QOL by means of ameliorating the most urgent symptoms such as bleeding from tumors, tumor-induced outlet obstruction, and malnutrition.

Gastrojejunostomy is a representative form of palliative surgery for gastric cancer and can be classified into several types of approaches, including reconstructive and gastric treatment procedures. Each approach has its own benefits and disadvantages. The appropriate choice of a procedure suitable for managing the particular symptoms in each individual patient is therefore important. The approaches are performed by laparotomy or by laparoscopic surgery and include simple (untreated) and complete or incomplete transection.

The simple type spares gastric treatment and has several disadvantages, including insufficient improvement in dietary intake, duodenal fluid reflux and bilious vomiting, bleeding from the tumor due to a direct contact of the cancer with food, and possible obstruction of anastomosis in a relatively short time after surgery due to the progression of cancer. Because patients are often in an undernourished state with anemia, hypoproteinemia, and edema in their organs, simple and reliable procedures are required for these patients.

The complete transection type of gastrojejunostomy involves complete transection of the stomach on the oral side of the cancerous site, followed by an anastomosis of the oral part of the stomach with the jejunum. Complete separation of the cancerous site from the healthy part of the stomach may prevent cancer invasion over the gastrojejunostomy, enabling the patient to take oral drugs and food for a longer period of time. However, complete transection eliminates an endoscopic observation of the cancerous site. In addition, the tumor progression probably causes pyloric obstruction, which could lead to an accumulation of gastric juice and oozed blood in the stomach and its subsequent rupture. Because of these disadvantages, ingenuity needs to be exercised in the use of external fistulas and other instruments. ⁷

The incomplete transection type of gastrojejunostomy, including gastric partitioning gastrojejunostomy, involves subtotal transection of the stomach from the greater curvature to the lesser curvature, leaving a narrow passage in the lesser curvature. An oral-side healthy part of the stomach is then anastomosed with the jejunum. This procedure is superior to the complete transection in protecting the anastomotic site against cancer invasion. Furthermore, this procedure can minimize bleeding from the surface of the tumor because it prevents a direct contact between food and the cancerous site.^8,9 An endoscopic examination is available in this method through the tunnel in the lesser curvature of the stomach. Previous reports have demonstrated that stomach-partitioning gastrojejunostomy is a safe and effective technique for unresectable distal gastric cancer, allowing the possibility of adequate oral intake and improvement of the QOL compared with classic gastrojejunostomy.^2,10–13 Thus, we recommend gastrojejunostomy in the form of incomplete transection.

Jejunal limbs for the bypass anastomosis may be elevated via the antecolic or retrocolic route. Recently, the latter route has been shown to be superior in improving postoperative dietary intake. In principle, however, the jejunum elevation is performed via the antecolic route because of its feasibility even for patients with an extensive mesocolon invasion.

Thus far, there has been no reliable comparative study between Billroth-II reconstruction and the Roux-en-Y procedure regarding their effects and efficacies. Some reports have indicated that the Billroth-II reconstruction, following distal gastrectomy, is more likely to induce gastritis in the residual stomach than Roux-en-Y reconstruction, because of the reflux of bile or pancreatic juice into the stomach. Some reports have suggested that the Roux-en-Y reconstruction is more likely to cause dumping syndrome, whereas others refute the association.^14,15 Because the Roux-en Y reconstruction can cause Roux stasis syndrome, neither of the reconstructive procedures is definitively more effective than the other. Because an occurrence of residual stomach gastritis significantly compromises the patient's QOL, bypass operations are generally performed using the Roux-en-Y method. ¹⁶

Peristaltic and antiperistaltic gastrojejunostomies have not been reported to differ from each other in terms of their functions. In this study, we used the antiperistaltic reconstruction for creating a stomach-partitioning gastrojejunostomy because the antiperistaltic side-to-side anastomosis with the use of mechanical devices does not cause stenosis in the efferent loop, in contrast to the peristaltic reconstruction method. ¹⁰

Reduced-port laparoscopic stomach-partitioning gastrojejunostomy is a form of palliative operation and offers the utmost priority to improve QOL for patients with unresectable advanced gastric cancer. ¹⁷ Because of less invasiveness of this procedure, patients can make a quick recovery from surgical stress and resume oral intake more quickly. Moreover, it may also facilitate the patients receiving chemotherapy with oral anticancer drugs, leading to the improvement in survival. In conclusion, our procedure is technically feasible and safe and will improve the patient's quality of end of life.