Recanalization in Uncut Roux-en-Y Reconstruction: An Animal Experiment and a Clinical Study

Abstract

Background: Because of the challenge of jejunal closure recanalization, uncut Roux-en-Y reconstruction remains controversial. This study aimed to investigate the incidence of recanalization after uncut Roux-en-Y reconstruction in pigs and a small number of patients. Methods: Twenty miniature pigs were subjected to distal gastrectomy and uncut Roux-en-Y reconstruction using various rows of linear staplers to block the intestine. The pigs were sacrificed, and the incidence of recanalization was investigated 1 month after the operation. From December 2018 to June 2019, 10 patients with gastric cancer who had undergone elective laparoscopy-assisted distal gastrectomy and uncut Roux-en-Y reconstruction were included in this study. The primary study outcome was recanalization of the afferent limb, demonstrated by gastrointestinal radiography 1, 3, and 6 months after surgery. Various numbers of staple lines across the afferent jejunal limb were applied for closure: 2 staple lines in 2 pigs, 4 staple lines in 6 pigs, 6 staple lines in 8 pigs, and 8 staple lines in 4 pigs. Results: Complete recanalization was detected in all 20 pigs 1 month postoperatively. Recanalization was detected in five cases (50%) by gastrointestinal radiography. Among them, 1 case of recanalization was found in the 1st month after the operation, 2 cases were found in the 3rd month, and another 2 cases were found in the 6th month. Bile reflux was detected by endoscopy in 2 patients with recanalization. Conclusions: The occurrence of afferent limb recanalization after uncut Roux-en-Y reconstruction is high, and using additional staplers alone cannot decrease the incidence of recanalization. Based on our study, uncut Roux-en-Y reconstruction is not recommended.

Keywords: complication; distal gastrectomy; gastric cancer; laparoscopic; uncut Roux-en-Y reconstruction.

Figure 1

General view of the surgical procedures.

Figure 2

Animal experiments. The intestinal cavity on the afferent limb 3 cm from the gastrojejunostomy anastomosis was closed using 6-row linear staplers (A) and 8-row linear staplers (B). After the pigs were sacrificed, the stapled site (white arrow) showed local indentation and a small amount of adhesion (C). Recanalization was detected grossly by opening the jejunal loop above the stapled partition (white arrow) (D). The operative site was harvested, and the stapled intestine (white arrow) was opened (E). The residual staplers (white arrow) remained in the mucosa (F).

Figure 3

Upper gastrointestinal radiography of patients with recanalization. Upper gastrointestinal radiography showed closure of the afferent limb (white arrows) 1 month after the operation (A) and recanalization (white arrow) 3 months after the operation (B). In another patient, upper gastrointestinal radiography showed closure of the afferent limb (white arrow) 3 months (C) after the operation and recanalization (white arrow) 6 months after the operation (D).

Figure 4

Gastroscopy of one patient with recanalization. Bile reflux (white arrow) through the afferent limb and a stomal ulcer were detected during endoscopy (A). The residual staplers (white arrow) remained in the mucosa of the afferent limb (B).