In both Korea and Japan, many surgeons tend to choose Billroth-I anastomosis following distal gastrectomy. Because of the technical difficulty of intracorporeal gastroduodenostomy, most surgeons have preferred laparoscopy-assisted distal gastrectomy (LADG) rather than totally laparoscopic distal gastrectomy (TLDG).(5) In 1992, we developed a simple and secure method of intracorporeal gastroduodenostomy, using only endoscopic linear staplers, which we have named the delta-shaped anastomosis.(6) This technique creates a functional end-to-end anastomosis between the posterior wall of the stomach and the duodenal bulb. Because of its advantages, this procedure is gaining widespread acceptance among surgeons in Japan and Korea, where it is becoming a standard reconstruction procedure in LDG.(5-10) Recently we reported the short and long-term outcomes of the initial 100 consecutive cases with a mean follow-up period of 54.9 months.(7) The learning curve for the surgeons was steep; mean time to perform the anastomosis was 13 minutes. One patient developed a minor anastomotic leak, and another suffered from postoperative dumping syndrome. Two-thirds of the patients tolerated a 1,500 kcal/day soft diet at the time of discharge. According to these results, we concluded that the delta-shaped anastomosis is safe, simple, and provides satisfactory postoperative outcomes.

With the acceptance of our delta-shaped anastomosis, several retrospective analyses comparing early surgical outcomes of TLDG using delta-shaped anastomosis with those of LADG have been reported.(8-11) In all of these studies, the reconstruction in LADG was performed with extracorporeal Billroth-I anastomosis, with a circular stapler. In TLDG groups the umbilical wound was extended up to 3 cm for specimen extraction, while in LADG groups, a 4~6 cm mid-line incision in the epigastrium was added. Early postoperative outcomes, such as blood loss, return of gastrointestinal function, pain scores, and hospital stay were significantly improved in TLDG compared with LADG.(9,10) Furthermore, in obese patients overall complication rates were significantly lower in TLDG than in LADG.(9) In performing LADG, the extracorporeal anastomosis that is done through a small incision can cause excessive traction on the organs and increase operative manipulation, especially in obese patients. To the contrary, in an intracorporeal anastomosis, direct visualization by laparoscopy provides a better operative field and minimizes surgical trauma; these advantages are also independent of body habitus.

Other techniques for intracorporeal Billroth-I anastomosis have been reported. Tanimura et al.(12) described a triangulating stapling technique with linear staplers. The posterior walls of the stomach and duodenal bulb are stapled in an inverted fashion, and the anterior walls are stapled with 2 staplers in an everted manner, making the shape of the anastomosis triangular. They reported on the feasibility of this procedure with their 111 cases experience. Omori et al.(13) described an intracorporeal circular-stapled Billroth-I anastomosis in a single-incision laparoscopic operation. They obviated the need for a purse-string suture for anvil head insertion into the duodenal bulb, and safely employed the technique in 20 patients.

The long-term surgical outcomes for these procedures are expected.

Roux-en-Y reconstruction is another option for distal gastrectomy, with the advantage of less bile reflux into the gastric remnant or reflux esophagitis. Similarly in LADG, Roux-en-Y reconstruction provided better surgical outcomes than Billroth-I reconstruction, preventing postoperative complications (i.e. anastomotic leak or stricture) and bile reflux into the gastric remnant.(14) However, long-term follow-up is still necessary, because Roux-en-Y gastrojejunostomies are considered relatively ulcerogenic.(15) There are other disadvantages as well: any subsequent need for endoscopic access to the ampulla of Vater is more difficult, and Roux-stasis syndrome, a unique complication of this procedure, may occur. Regarding the anastomotic techniques, both linear staplers(16-18) and circular staplers(19,20) have been reported with successful results. The uncut Roux-en-Y method using a linear stapler provided better results in preventing Roux-stasis syndrome.(16) Noshiro et al.(17) reported a novel stapling technique with linear staplers that is possible when the residual stomach is small. Circular stapling techniques have been used by transoral anvil placement.(20) Elimination of the purse-string suture has also been described.(21) Long-term follow-up results with larger number of patients are expected.

Billroth-II anastomosis is another standard method of reconstruction, although there are some concerns of gastric remnant carcinogenesis due to alkaline reflux gastritis.(22,23) There are reports using both linear(16,24) and circular staplers.(25) When using linear staplers, care must be taken to avoid stricturing of the efferent loop of the jejunum, especially when the entry hole is closed with a stapler.(16) Uyama et al.(16) make the enterotomy on the afferent loop and perform an antiperistaltic Billroth-II anastomosis, placing some stitches between the afferent loop and the lesser curvature of the gastric remnant to prevent food from flowing into the afferent loop. We think these concepts are reasonable, and may provide better surgical outcomes for patients.

Functional end-to-end anastomoses for esophagojejunostomy have been reported.(5,26-27) One technique is fashioning an antiperistaltic side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was also closed with staplers.(26,27) A nasogastric tube, as an insertion guide to the esophageal lumen, was quite helpful for identification of the lumen.(27) An isoperistaltic esophagojejunostomy, the so-called 'Overlap method' has also been reported,(28-30) in which the entry hole was closed with intracorporeal hand-sewn sutures. Because the anastomosis is made in an isoperistaltic manner, the jejunal limb straightens, which may be advantageous when the anastomosis is located in the confined mediastinal space.(28)

The esophagojejunostomy with a circular stapler is a common method in conventional open total gastrectomy, and surgeons are familiar with this procedure. However, it is often difficult to complete circular-stapled esophagojejunostomy through a mini-laparotomy, because inserting and/or fixing the anvil in a narrow and deep operative field can be difficult, especially in obese patients. With improvements of surgeons' skills and dedicated devices, an intracorporeal circular-stapled anastomosis has become more practical. Novel procedures include an endoscopic purse-string suture instrument 'Endo-PSI(II)',(31) transorally inserted anvil (Orvil™, Covidien, Mansfield, MA, USA),(32,33) hand-sewn purse-string suturing techniques,(34) and hand-sewn esophagojejunostomy(35) have been developed. The insertion and fixation of the anvil becomes easier with these devices and techniques. Early surgical outcomes using the Orvil™ have been reported. Operative time and blood loss were reduced compared to anastomosis with mini-laparotomy.(32) Adequate extension of the neck, appropriate selection of the anvil head,(32) and caution in the insertion of the anvil, to prevent larynx or esophageal injury, are crucial. Preventing abdominal infection is also important when using Orvil™.(33)

Techniques with both linear and circular staplers in LTG seem feasible, but most of the data are technical reports with a limited number of patients. Further study including larger number of patients, and comparison studies with other techniques measuring short-term and long-term surgical outcomes are warranted to evaluate these anastomotic procedures.