Patients
This study adopted a retrospective design to compare the clinical efficacy and quality of life of patients with B-II and B-IIB reconstruction after laparoscopic distal gastrectomy. Between February 2016 and January 2022, 158 patients underwent laparoscopic distal gastrectomy. Preoperative ultrasonography and abdominal computed tomography were performed to evaluate the clinical stage. All patients were diagnosed as gastric adenocarcinoma by preoperative endoscopic biopsy. Endoscopic clipping was performed preoperatively to identify intraoperative lesions in all patients. Two surgeons participated in the study. Of these patients, 93 patients underwent B-IIB reconstruction, and 65 patients underwent B-II reconstruction. All data have been retrieved prospectively, and we retrospectively analyzed the following variables:(1) Patient demographics (i.e. age, gender, height, weight, body mass index (BMI)); (2) Perioperative period, postoperative recovery and clinicopathological data (i.e. operation time, blood loss, tumor size, depth of invasion, lymph node status, time to first anal wind, time to removal of abdominal drainage tube, length of hospital stay, and postoperative complications); (3)The changes of hemoglobin (Hb), albumin (ALB), total protein and electrolytes (Serum calcium, potassium, sodium, chloride ) before operation and at 3 days and 3 months after operation in the two groups of patients; (4) According to the Postgastrectomy Syndrome Assessment Scale PGSAS-45 (Postgastrectomy Syndrome Assessment Scale), it was designed by the Japan Postgastrectomy Syndrome Assessment Collaborative Group [8] to objectively and comprehensively evaluate the postoperative prognosis of patients after gastrectomy. Postoperative complications, postoperative living status and quality of life (esophageal reflux symptoms, abdominal pain symptoms, eating discomfort, dyspepsia, dumping syndrome)
Surgical Approach
Dissociate gastric tissue and perform D2 lymph node dissection
Pull down the colon, lift the omentum, use a harmonic scalpel to dissociate the omentum and the anterior page of the transverse mesocolon from the right starting part of the omentum, dissociate the omentum to the upper left, separate the left gastroepiploic blood vessel, and cut it off after attaching a titanium clip, and dissection of group No.4 lymph nodes. Pull up the stomach, peel the pancreatic capsule to the upper edge of the pancreas with ultrasonic scalpel, separate the right gastroepiploic artery and vein at the root of the upper edge of the head of the pancreas, cut off after the titanium clip placed, remove the sixth group of lymph nodes, and remove the anterior duodenum appendage,the lymph node and connective tissue.The stomach was lifted, the lymph nodes next to the common hepatic artery and the upper border of the pancreas were separated and removed, the right gastric artery and vein were separated from the common hepatic artery to the right.A titanium clip was placed on the root to cut off, and the first segment of the duodenum was dissociated. The celiac trunk and splenic artery were exposed to the left along the common hepatic artery, the No.8, No.9, and No.10 lymph nodes were removed, the left gastric blood vessels were separated, and titanium clips were placed on the roots to cut them off, and the No.7 group lymph nodes were dissected. The lesser omental sac was opened, and the lymph nodes of group No.5, group No.3, and group No.1 were dissected to the right lymphatic and fatty tissue of the cardia, and the distal stomach was completely dissociated.
Dissection of the distal stomach
We used a linear cutting and closure device 3 cm below the pylorus to close the severed duodenum. The line connecting the midpoint of the lesser curvature to the avascular area of the greater curvature is used as the pre-cut line, and the cutting and closure device is used for the pre-cut. The distal stomach was severed by planar closure, and the specimen was extracted.
Billroth II Braun anastomosis
Opened the small bowel wall 40cm away from the ligament of Treitz, made a 1cm incision in the posterior wall of the greater curvature of the remnant stomach, a cutting and closure device was placed, the remnant stomach and jejunum were anastomosed side-to-side, and the common opening was closed with a posterior silk thread. The jejunum was elevated, and the input loop at 15 cm below the gastrojejunostomy was anastomosed side-to-side with the output loop about 30 cm below the anastomosis, with an anastomosis length of about 4 cm. Braun's anastomosis is completed with barbed suture and reinforcement of the common opening.
Billroth II anastomosis
The small bowel wall was opened 40 cm away from the ligament of Treitz, a 1 cm incision was made in the posterior wall of the greater curvature of the remnant stomach, a cutting and closure device was placed, and the remnant stomach and jejunum were anastomosed side-to-side, and the common opening was closed with a silk thread.
The Pgsas-45 Questionnaire
The PGSAS-45 questionnaire[12] was distributed to the patients 3 months after the operation. The scores of each item were collected, and the main symptom scores were combined to obtain the main symptoms. The main symptoms include: esophageal reflux, abdominal pain, eating-related discomfort, dyspepsia, dumping syndrome. PGSAS-45 and the characteristics of PGS after gastrectomy were used to summarize the patients and confirm their quality of life and living conditions.(Table 1, Fig. 1)
Table 1
The PGSAS-45 questionnaire distributed to the patients 3 months after the operation
Symptoms of esophageal reflux(Item numbe10,11,13,14) |
Suffer from heartburn (It refers to burning pain or discomfort behind the sternum.) |
Suffer from gastric acid reflux.(Sour or bitter liquid flows back into your mouth.) |
Feel nausea |
Suffer from bile reflux. (Bitter in the mouth.) |
abdominal pain symptoms(Item numbe9,12,28) |
Suffer from stomach pain or abdominal pain. |
Suffer from hunger pain in the stomach or abdomen. |
Suffer from periumbilical pain or lower abdominal pain. |
Eating discomfort(Item numbe25-27) |
Disturbed by the sense of adhesion when swallowing food. (I feel uncomfortable when food accumulates on my chest.) |
Suffer from feeling full after meals. (Feels uncomfortable or heavy when food accumulates in the stomach.) |
Suffer from the feeling of satiety caused by eating a small amount of food |
Indigestion (Item numbe14-17) |
Disturbed by the rumble of the stomach or abdomen |
Feel bloated or distended |
Suffer from hiccups |
Troubled by increased exhaust |
Dumping syndrome(Item numbe30,31,33) |
Disturbed by the general symptoms of dumping syndrome (cardiopalmus, cold sweats, fatigue and pallor occur within half an hour of eating) |
Disturbed by dumping syndrome(Nausea and vomiting, abdominal cramps, diarrhea occur within half an hour of eating) |
Within 3 hours of eating, people are troubled by dumping syndrome (cold sweat, palpitations, dizziness, headache, syncope, fatigue, weakness, anxiety, trembling, hunger, shortness of breath) |
Statistical Methods
The statistical analysis was performed using SPSS.25.For continuous variables, the normal distribution was satisfied, independent samples t test was used for analysis, and the analysis was performed as mean ± standard deviation(SD); chi-square test was used to compare the categorical variables, which was expressed as N (Percent) and expressed as p value of 0.05 or lower was used as the criterion for judging statistical significance.