J Korean Surg Soc 2012;83:274-280 JKSS http://dx.doi.org/10.4174/jkss.2012.83.5.274 Journal of the Korean Surgical Society pISSN 2233-7903ㆍeISSN 2093-0488 ORIGINAL ARTICLE Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients Ki Han Kim, Min Chan Kim, Ghap Joong Jung Department of Surgery, Dong-A University College of Medicine, Busan, Korea Purpose: Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer. Methods: Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diame- ter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastro- intestinal series or endoscopy. Results: Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with de- layed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass in- dex, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multi- variate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040). Conclusion: In this study, the circular stapler diameter was one of the most significant predictable fac- tors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gas- tric emptying associated with anastomosic stenosis or edema with relative safety. Key Words: Gastric emptying, Gastrectomy, Billroth-I, Gastric neoplasms INTRODUCTION distal gastrectomy. It provides more physiologic flow of food contents through the duodenum and decreases the More than 100 years have passed since Billroth first de- possibility of metabolic problems and nutritional defi- scribed his procedure of reconstruction in 1881. Billroth I ciency [1]. Since the introduction of surgical stapling de- gastroduodenostomy has been the procedure of choice for vices, Ravitch and Steichen [2] reported his experiences of Received May 7, 2012, Revised July 30, 2012, Accepted August 5, 2012 Correspondence to: Min Chan Kim Department of Surgery, Dong-A University College of Medicine, 26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea Tel: ＋82-51-240-2643, Fax: ＋82-51-247-9316, E-mail: [email protected] cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2012, the Korean Surgical Society Delayed gastric emptying after subtotal gastrectomy gastroduodenostomy using an end-to-end anastomosis 2003 and December 2008 were included in the present (EEA) stapler in 1979, and Oka et al. [3] reported that gas- study. Among the 378 patients, laparoscopy assisted distal troduodenostomy was performed using a double-stapling gastrectomy was performed in 264 cases, and conven- technique with EEA, which was separate from the anvil. tional distal gastrectomy was performed in 114 cases. One Since then, Billroth I gastroduodenostomy with a circular hundred and eighty-two patients underwent Billroth-I stapler has become a popular method of anastomosis for anastomosis using a 25 mm diameter circular stapler, and gastric cancer, because it has several merits, including sta- 196 patients had anastomosis with a 28 or 29 mm diameter bility, simplicity, reduced operative time, etc. circular stapler. Clinicopathologic features such as age, Distal gastrectomy can lead to postgastrectomy syn- gender, body mass index (BMI), comorbidity disease, tu- dromes such as dumping syndrome and reflux esoph- mor size, histologic type, tumor location, resection mar- agitis, which are closely related to the rate of gastric emp- gin, tumor-node-metastasis stage, and postoperative out- tying [4,5]. Prolonged gastric stasis after gastric surgery comes were reviewed. DGE was diagnosed by patients’ may occur occasionally, and most patients are able to eat a symptoms and simple abdomen X-ray with or without up- regular diet within 7 to 10 days after operation. The re- per gastrointestinal series or endoscopy (Fig. 1). ported incidence of delayed gastric emptying (DGE) after All the values were expressed as means ± standard devi- gastrectomy has been reported to range from 5 to 30% ations (SDs). Postoperative follow-up periods were ex- [6-8]. pressed as median ± SDs. Gastric cancer stage was classi- Therefore, we evaluated DGE in patients who under- fied according to the seventh edition of the American Joint went radical subtotal gastrectomy with Billroth I gastro- Committee on Cancer staging criteria [9]. The patients en- duodenostomy for early gastric cancer using a circular rolled in this study underwent standard D2 or above ac- stapler. Also, we analyzed the predictable factors asso- cording to the 2010 Japanese gastric cancer treatment ciated with DGE. guidelines (ver. 3) [10]. Surgical procedures METHODS Conventional distal gastrectomy with Billroth I gastro- duodenostomy with lymphadenectomy was performed Patient selection according to the 2010 Japanese gastric cancer treatment Patients with early gastric cancer treated with circular guidelines (ver. 3) [10]. Laparoscopy-assisted distal gas- stapled Billroth I gastroduodenostomy between January trectomies were performed according to the standard pro- Fig. 1. Radiologic and endoscopic finding of delayed gastric emptying. (A) Simple abdomen X-ray shows dilated stomach with food material. (B) Severe stenosis of anastomosis site after Billroth I gastroduodenostomy. Opening is seen at inferior direction of anastomosis site. Opening was too small for endoscope to pass through. Ulcer lesion is seen below anastomotic site. (C) Endoscopic view of gastroduodenostomy stenosis undergoing balloon dilatation. Luminal narrowing is seen due to anastomotic stenosis. Balloon dilatation by 20→25→30 psi was done for 2 minutes. There developed no complication such as bleeding due to procedure. Widening of stenosis site can be seen. thesurgery.or.kr 275 Ki Han Kim, et al cedure guidelines as described in a previous report [11]. In mm diameter stapler. There were statistically significant the early period of laparoscopy assisted distal gas- differences in gender, BMI, presence of comorbidity, oper- trectomy, we applied a 25 mm diameter circular stapler to ation method, operation time, presence of complication, the Billroth I gastroduodenostomy, because a 25 mm di- and presence of DGE between the two sizes of stapler ameter circular stapler was suitable forsmall wounds. After gaining experience with laparoscopy assisted distal Ta ble 1 . Clinicopathological and postoperative outcomes gastrectomy, we applied a 28 or 29 mm diameter circular according to presence of delayed gastric emptying stapler to the Billroth I gastroduodenostomy even if the DGE Non-DGE Variable P-value wound size was small. In contrast, we used a 28 or 29 mm (n = 12) (n = 366) diameter circular stapler during the Billroth I gastro- Age (yr) 61.7 ± 13.5 58.7 ± 11.6 0.380 duodenostomy of conventional distal gastrectomy from Gender 0.363 the beginning. Male 6 236 Female 6 130 Body mass index (kg/m2) 22.7 ± 1.6 23.5 ± 2.7 0.273 Statistical analysis Comorbidity 0.920 Clinical characteristics of patients were summarized as No 8 249 Yes 4 117 a whole, as well as described specifically for subgroups by Size of main lesion (mm) 2.6 ± 1.5 2.5 ± 1.6 0.996 descriptive statistics. After descriptive analyses were per- Histologic type 0.378 formed, a Fisher’s exact test was used to compare catego- Well differentiated 8 142 Moderately differentiated 2 84 rical variables between groups, while a Student’s t-test was Poorly differentiated 2 105 used to compare continuous variables between groups. Signet ring cell 0 30 Odds ratio (OR) for comparison of the two groups was Others 0 5 Tumor location 0.475 summarized with its 95% confidence interval (CI) and Middle 1 72 P-value using logistic regression. The multivariate model Lower 11 294 was created using a backward elimination method, and Resection margin (cm) Proximal 5.4 ± 2.8 5.7 ± 3.0 0.731 the probability was set at 0.20 for removal. ORs were also Distal 3.9 ± 1.6 5.5 ± 2.7 0.045 adjusted for factors affecting the response variable. P-val- Stagea) 0.788 ues lower than 0.05 were considered statistically signi- 0 0 5 I 12 352 ficant. All statistical analyses were carried out using II 0 9 PASW ver. 18.0 (IBM Co., Armonk, NY, USA). Operation method 0.117 Open 1 113 Laparoscopy 11 253 Circular stapler 0.017 RESULTS diameter (mm) 25 10 172 28 or 29 2 194 Patient characteristics Operative times (min) 202.5 ± 38.5 181.6 ± 50.8 0.159 Among the 378 patients, postoperative DGE was found Hospital stay (day) 7.3 ± 1.4 7.5 ± 6.1 0.924 in 12 patients (3.2%). Clinicopathological and postopera- Complication 0.775 No 11 343 tive outcomes for the 378 patients with regard to the pres- Yes 1 23 ence of DGE are shown in Table 1.