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Modification of book-binding technique during totally laparoscopic distal gastrectomy with Billroth I reconstruction


 Division of Digestive Surgery, Ehime Prefectural Central Hospital, Ehime, Japan

Date of Submission13-Jul-2021
Date of Acceptance24-Nov-2021
Date of Web Publication04-Jan-2022

Correspondence Address:
Yuhei Waki,
83 Kasuga-Cho, Matsuyama, Ehime 790-0024
Japan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_236_21

PMID: 35046180

  Abstract 


The book-binding technique (BBT) has been developed to minimise extra detachment and mobilisation of the duodenum for totally laparoscopic distal gastrectomy (TLDG) with Billroth I reconstruction. Because of the cost-effectiveness and maximisation of the anastomotic lumen, we have modified the BBT in collaboration with the laparoscopic hand-sewing technique. Herein, we introduce a modified BBT (MBBT) and discuss its outcomes. The MBBT was performed using laparoscopic hand-sewing techniques with an absorbable barbed suture instead of using linear staples to close the defect of the anterior wall of the anastomosis site. The data of 163 patients with gastric cancer who underwent TLDG with Billroth I reconstruction performed with MBBT were retrospectively collected between April 2014 and December 2019. The mean anastomosis time was 25 min (interquartile range, 21 − 30). Postoperative complications of Clavien-Dindo grade II or greater occurred in 20 of the 163 patients (12.3%). Anastomotic leakage occurred in three patients (1.8%), whereas anastomotic stenosis occurred in one patient (0.6%). The cumulative incidence rate of anastomotic stenosis that required endoscopic dilation at 1 year was 1.2%. The MBBT method may be safe, practical, cost-effective and results in reduced staple use and anastomotic time.


Keywords: Billroth I reconstruction, book-binding technique, laparoscopic distal gastrectomy



How to cite this URL:
Waki Y, Masayoshi O, Sato K, Yagi S. Modification of book-binding technique during totally laparoscopic distal gastrectomy with Billroth I reconstruction. J Min Access Surg [Epub ahead of print] [cited 2022 Jul 1]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=334796





  Introduction Top


Totally laparoscopic intracorporeal resection and laparoscopic techniques for anastomosis have been developed to minimise wound size and invasiveness. The book-binding technique (BBT) for intracorporeal Billroth I reconstruction was introduced in 2014.[1] The surgical advantage of this technique is that it minimises detachment and mobilisation of the duodenum and the formation of ischemic areas around the anastomosis site. In April 2015, our department switched from laparoscopic-assisted to totally laparoscopic distal gastrectomy (TLDG). Thereafter, we modified the BBT in collaboration with the laparoscopic hand-sewing technique to reduce the use of staples. Herein, we introduce our modified BBT (MBBT) anastomosis and investigate its outcomes retrospectively at our single institution.


  Surgical Techniques Top


Laparoscopic distal gastrectomy and lymph node dissection were performed according to the guidelines of the Japanese Gastric Cancer Association,[2] using five trocar methods in the open leg position under general anaesthesia. A mini-laparotomy of <4 cm at the umbilical region was performed for specimen retrieval. After removing the distal stomach, reconstruction was performed using the MBBT. First, small entry holes were created on the greater curvature side of the remnant stomach and duodenal stump. After extending each entry hole on the anterior side, endoscopic linear stapler forks were inserted at least 35 mm into the entry holes through the left lower port [Figure 1]a. The duodenum and remnant stomach were attached and sutured. All transection lines, including the stapler line on the duodenum, the anterior side of the anastomosis line between the duodenum and remnant stomach, and approximately one-fourth of the transection lines on the stomach were dissected using an ultrasonic coagulation cutting device to prevent the formation of duodenal ischaemic areas, and a hole was created in the anterior side of the anastomosis site [Figure 1]b. Subsequently, using a 3/0 absorbable barbed suture (V-loc™ 180, Medtronic Inc, Minnesota, USA), a laparoscopic continuous hand-sewing suture was started at the edge of the lesser curvature [Figure 1]c. Two stitches were placed to reinforce the posterior sutured wall from inside-outside to outside-inside. A continuous inside-outside suture (Schmieden's suture) was performed, alternating between the stomach and duodenum through the anterior side of the anastomosis to the edge of the greater curvature [Figure 2]a. After suturing the edge of the greater curvature, two or three stitches were added to the entire or serosal muscular layer to prevent the continuous suture from slipping [Figure 2]b. Finally, the MBBT was completed [Figure 2]c.
Figure 1: The first step of the modified book-binding technique. (a) The insertion of a stapler into the duodenum and remnant stomach. (b) Transection lines (broken lines). (c) The starting point for a laparoscopic hand-sewing suture at the edge of the lesser curvature side of the sutured posterior wall

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Figure 2: The second step of the modified book-binding technique. (a) The continuous inside-outside suture. (b) Additional stitches in the entire layer or serosal muscular layer. (c) Image obtained after completion of the book-binding technique

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  Benefits Top


Clinicopathological factors and surgical outcomes of our MBBT were evaluated. This study was approved by the Institutional Review Board of our hospital (03–08). The requirement for informed consent was waived by the ethical committee owing to the retrospective nature of the study. Clinical factors are shown in [Table 1]. The anastomotic time was defined as the duration from the insertion of the stapler (after cutting the stump of the stomach and duodenum) to the completion of the anastomosis. Surgical outcomes are shown in [Table 2]. The mean operative time was 230 min (interquartile range, 210 − 259). The mean anastomosis time was 25 min (interquartile range, 21 − 30). Post-operative complications of Clavien-Dindo grade II or greater occurred in 20 of the 163 patients (12.3%). Anastomotic leakage occurred in 3 patients (1.8%), while anastomotic stenosis occurred in 1 patient (0.6%). The cumulative incidence rate of anastomotic stenosis that needed endoscopic dilation at 1 year was 1.2%.
Table 1: Clinical findings

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Table 2: Surgical outcomes

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Various methods of totally laparoscopic intracorporeal anastomosis have been developed. BBT anastomosis is reportedly simpler than the other anastomoses in terms of avoiding extra manipulations and twists of the duodenum.[1] A previous study reported that BBT anastomosis was as feasible and safe as the double stapling method using a circular stapler; however, it took shorter anastomosis time and more stapler cartridges used compared to the double stapling method using a circular stapler during TLDG with the intracorporeal anastomosis.[3] Thus, we MBBT in collaboration with a laparoscopic hand-sewing technique to reduce the use of staples. Moreover, our MBBT does not require additional excision of anterior gastric and duodenal wall tissues, which increases the tension over the anastomosis site by hand-sewn closure of the anterior anastomotic side compared to the original BBT method using linear staples. As absorbable barbed sutures cost approximately 30 −45 USD per thread and stapler reloads cost approximately 100 −200 USD, a cost difference of about 50 −150 USD should result from the application of this technique. However, the total cost of surgery could not be investigated because of the retrospective nature of the study. Therefore, further study is required to investigate the total cost.

The hand-sewing technique used in our MBBT was slightly more challenging for inexperienced operators compared to experienced operators, and some experience was required to perform it. A total of 18 operators, including experienced laparoscopic and resident surgeons, performed this technique in this study. [Figure 3] demonstrates the learning curve associated with this technique for operators who performed more than 15 cases. Anastomotic time gradually decreased as more cases were performed. This suggests that anastomotic time can be shortened with sufficient experience.
Figure 3: Learning curves of each operator who performed more than 15 cases using the modified book-binding technique

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Recently, Kim et al. reported the safety and feasibility of MBBTs as well as the reduced staple use associated with them.[4] Our MBBT is unique in that it involves performing a continuous inside-outside suture at the anterior walls of the duodenum and stomach with absorbable barbed sutures from the back to the front of the laparoscopic field. This made it easier to handle the needle without making a large motion (such as twisting or turning) over the posterior wall of the anastomosis site. Our mean anastomotic time tended to be shorter than that reported previously (26.2 min vs. 52 min).[4] In addition, the incidence of postoperative anastomotic complications including anastomotic stenosis and leakage were low and comparable to previous reports.[1],[3],[4],[5] All these points suggest that the hand-sewing method used in our MBBT is safer for patients and therefore, superior to those used in other MBBTs.

In conclusion, we have presented a safe, practical, and potentially more efficient MBBT that resulted in reduced staple use and anastomotic time.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Oki E, Tsuda Y, Saeki H, Ando K, Imamura Y, Nakashima Y, et al. Book-binding technique for Billroth I anastomosis during totally laparoscopic distal gastrectomy. J Am Coll Surg 2014;219:e69-73.  Back to cited text no. 1
    
2.
Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 2017;20:1-19.  Back to cited text no. 2
    
3.
Ikeda T, Kawano H, Hisamatsu Y, Ando K, Saeki H, Oki E, et al. Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: Comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis. Surg Endosc 2013;27:325-32.  Back to cited text no. 3
    
4.
Kim JS, Park EY, Park DJ, Kim GY. Modified Book Binding Technique (MBBT) for intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy: Initial experience. J Gastric Cancer 2019;19:355-64.  Back to cited text no. 4
    
5.
Katai H, Mizusawa J, Katayama H, Morita S, Yamada T, Bando E, et al. Survival outcomes after laparoscopy-assisted distal gastrectomy versus open distal gastrectomy with nodal dissection for clinical stage IA or IB gastric cancer (JCOG0912): A multicentre, non-inferiority, phase 3 randomised controlled trial. Lancet Gastroenterol Hepatol 2020;5:142-51.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04