Analysis of Clinical Efficacy and Quality of Life of Braun Anastomosis in Gastrointestinal Reconstruction in Totally Laparoscopic Distal Gastrectomy: A Single-center Retrospective

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Analysis of Clinical Ecacy and Quality of Life of Braun Anastomosis in Gastrointestinal Reconstruction in Totally Laparoscopic Distal Gastrectomy: A Single-center Retrospective Study Yayan Fu 
Medical College of Yangzhou University Jun Ren 
Medical College of Yangzhou University Yue Ma 
Northern Jiangsu People's Hospital Jiajie Zhou 
Yangzhou University Wenzhe Shao 
Yangzhou University Guowei Sun 
Yangzhou University Qiannan Sun 
Research Article
Posted Date: November 3rd, 2022
DOI: https://doi.org/10.21203/rs.3.rs-2217694/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.   Read Full License
Abstract
Objective This study aimed to compare the clinical ecacy and quality of life of B-IIB( Billroth-II with Braun anastomosis) and B-II (Billroth-II anastomosis) in the alimentary tract reconstruction postoperative totally laparoscopic distal gastrectomy (TLDG) for gastric cancer.
Methods From February 2016 to January 2022, 158 patients underwent totally laparoscopic distal gastrectomy and D2 lymphadenectomy in Northern Jiangsu People’s Hospital, with Billroth-II with Braun anastomosis for 93 patients and Billroth-II anastomosis for 65 patients. The patients’s data were collected prospectivly and reviewed retrospectively.
Results In this study, the post-op hospital stay for B-IIB group were shorter than for B-II group (12.70 ± 3.08 days in the B-IIB group versus 14.12 ± 4.90 days in the B-II group, p < 0.05) and the rst post-op anal wind time for the B-IIB group were shorter than for B-II group (3.49 ± 1.02 days versus 4.08 ± 1.85 days, p < 0.05). Two groups did differ signicantly in hemoglobin on postoperative 3 months, albumin at 3 months after operation and serum sodium on postoperative 3 days and 3 months (p < 0.05), and the B-IIB had an advantage; the incidence of complications of Clavien-Dindo grade II or higher in the B-IIB group and B-II were 10.75% and 29.23%, respectively. There being a statistical difference between the two groups. The B- IIB group and the B-II group both had different degrees of weight loss at 3 months after operation compared with preoperative weight. The weight of Billroth-II combined with Braun reconstruction group was 4.04 ± 1.33 kg, which was less than 8.08 ± 1.47kg of Billroth-II reconstruction group.The difference was statistically signicant (p < 0.05). According to the PGSAS ( Postgastrectomy Syndrome Assessment Scale), the score of the Billroth-II with Braun reconstruction group is lower than that of the Billroth-II reconstruction group for esophageal reux gastritis, dyspepsia and dumping syndrome group (1.84 ± 0.92 VS 2.15 ± 0.85, P = 0.031; 1.86 ± 1.10 VS 2.22 ± 0.91, P = 0.034; 1.98 ± 1.06 VS 2.32 ± 0.94, P = 0.037, respectively).
Conclusion Totally laparoscopic distal gastrectomy with Billroth-II Braun reconstruction is a safe and technically feasible method for gastric cancer patients, which can reduce the incidence of postoperative reux esophagitis and dumping syndrome. Compared with Billroth-II reconstruction,it has advantages in maintaining postoperative nutritional status and electrolyte balance and improving quality of life.
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Introduction Gastric cancer was estimated to be the sixth most common malignant neoplasm worldwide, the it is the third leading cause of mortality among all malignant neoplasm[1]. With the development of basic research and the advancement of clinical trials, the medication treatment of gastric cancer (chemotherapy, targeted therapy, immunotherapy, etc.) has evolved in a diversied and comprehensive manner, but the overall strategy of gastric cancer treatment at present is still depended on surgical treatment.Radical surgical resection is still the only curable treatment for gastric cancer[2]. Radical resection of gastric cancer mainly includes two steps, the rst one is complete gastric tumor resection and thorough lymph node dissection, and the other is digestive tract reconstruction. The rst one is the most important factor affects the long-term survival of post-op gastric cancer patients, while the latter is closely related to the short-term post-op safety[3].In1994, Kitano et al. published the rst description of the laparoscopic method to the treatment of gastric cancer—in the form of a laparoscopy-assisted distal gastrectomy. In recent years, laparoscopy has emerged as a preferred option for gastric cancer due to its minimal invasive nature and benets for short-term surgery[4].
The choice of surgical approach depends on the location of the primary tumor, the depth of tumor inltration, and the diculty of surgical operation. According to the 15th edition of the Japanese "Stomach Cancer Treatment Protocol",[5]radical distal gastric resection with subtotal resection D2 lymph node dissection is recommended for the lower third of the stomach. With recent advances in laparoscopic surgery, equipments and surgical skills have expanded the scope of surgery. This is the basis for performing lymph node dissection above D2. As a result, the interests of surgeons and patients have shifted towards a quality of life that goes beyond curability[6].
Various ways of gastrointestinal reconstruction comes after lymph node dissection and tumor resection, each one has its own merits and demerits: Billroth I reconstruction is widely used because of its physiological advantages, but it cannot be applied to the individual with the strong anastomotic tension and suffers a high risk of anastomotic leakage in all patients[7]; Billroth II reconstruction solved the problem of anastomotic tension, but it may increase the incidence of postoperative alkaline reux gastritis, esophagitis and anastomotic ulcers[8, 9],due to changing normal physiological pathways. Such that Braun anastomosis comes up with the purpose to allow the digestive juices of the input loop to "shortcut" into the output loop. Previous retrospective studies demostrate that Braun anastomosis has great advantages in preventing bile reux gastritis and dumping gastritis[10, 11].
Although the Braun anastomosis is commonly proceeded, there being just few reports directly compare B- II B and B-II. In this study, a variance analysis was performed from our single-center data to assess which reconstruction method was more effective in reducing Post-complication symptoms after surgery and better in improving the quality of life of patients, especially in bile reux and reux esophagitis. It provides experiences for future digestive tract reconstruction techniques
Materials And Methods
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Patients This study adopted a retrospective design to compare the clinical ecacy 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 rst 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 reux 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 rst 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,
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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 reux, abdominal pain, eating-related discomfort, dyspepsia, dumping syndrome. PGSAS-45 and the characteristics of PGS after gastrectomy were used to summarize the patients and conrm their quality of life and living conditions.(Table 1, Fig. 1)
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Table 1 The PGSAS-45 questionnaire distributed to the patients 3 months after the operation
Symptoms of esophageal reux(Item numbe10,11,13,14)
Suffer from heartburn (It refers to burning pain or discomfort behind the sternum.)
Suffer from gastric acid reux.(Sour or bitter liquid ows back into your mouth.)
Feel nausea
abdominal pain symptoms(Item numbe9,12,28)
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)
Feel bloated or distended
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
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The statistical analysis was performed using SPSS.25.For continuous variables, the normal distribution was satised, 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 signicance.
Results Analysis of general clinical data
According to the inclusion and exclusion criteria, 158 patients were enrolled in this retrospective study, 93 patients underwent B-IIB surgery and 65 patients underwent B-II surgery. The characteristics of the enrolled patients are summarized in Table 1.The two groups did not differ siginicantly in age(p = 0.308), gender(p = 0.995), tumor size(p = 0.209),and BMI(p = 0.135),. In conclusion, there was no signicant difference in the general clinical data and pathological data between the two groups, and the data between the two groups were comparable.
Comparison of perioperative data and postoperative pathological data between two groups of patients
 
p value
Table 2 General data, perioperative data, postoperative pathological data and analysis of nutritional status data
Age (years) 61.05 ± 9.66 59.27 ± 11.43 1.024 0.308
Sex     0 0.995
Male 44(67.69) 63(67.74)    
Female 21(32.31) 30(32.26)    
64.392 ± 10.060
-1.561 0.121
Weight loss 3 months after surgery(kg) 8.077 ± 1.472 4.043 ± 1.326 17.979 0.000**
height(cm) 165.45 ± 6.84 165.80 ± 7.66 -0.295 0.769
BMI(kg/m2) 22.66 ± 3.01 23.42 ± 3.20 -1.502 0.135
Tumor size (cm) 2.72 ± 1.34 3.01 ± 1.50 -1.262 0.209
T stage     0.942 0.815
Operative time (min) 160.08 ± 28.66
167.05 ± 33.67 -1.361 0.176
Blood loss (ml) 58.77 ± 35.38 67.85 ± 38.50 -1.531 0.128
Hospital stay (days) 14.12 ± 4.91 12.70 ± 3.08 2.072 0.041*
Time to rst anal exhaust (days) 4.08 ± 1.85 3.50 ± 1.02 2.307 0.023*
Abdominal drainage tube pull-out time(days)
9.55 ± 4.12 8.72 ± 2.39 1.467 0.146
Analysis of the nutritional status of the two groups of patients before surgery, 3 days and 3 months after surgery
The preoperative hemoglobin (Hb), albumin (ALB), total protein and serum calcium and serum sodium mean of patients in B-IIB group and B-II group had no signicant difference in preoperative nutritional
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status indicators between the two groups, hemoglobin (Hb) and albumin (ALB) were re-examined 3 days after operation in the two groups, and total protein was re-examined 3 months after operation. The two groups did not differ signicantly in nutritional status indicators. The mean value of HGB in group B-IIB was 118.57±19.82 at 3 months after operation, and the mean value of Hb in group B-II was 126.97±24.02 at 3 months after operation, showing a signicant difference (p=0.022); The mean value of ALB of group B-IIB at 3 months after operation was 40.64±4.71, and the mean value of ALB at 3 months after operation in group B-II was 39.14±5.68, showing a statistically signicant difference (p=0.003) (table 2, 3, 4). There was no statistical difference between the two groups of patients in the re-examination of serum calcium 3 months after the operation. The re-examination of the serum sodium on the postoperative 3 Days and 3 months respectively, p=0.000, p=0.014. In conclusion, it can be considered that B-IIB has the advantage of promoting early postoperative recovery compared with B-II in the treatment of laparoscopic distal gastric cancer patients.(table 3)
  Table 3
  B-II Braun (N = 93) Billroth-II (N = 93)  
Before operation      
ALB(g/l) 44.46 ± 4.23 44.14 ± 6.01 0.71
serum sodium (mmol/L) 140.62 ± 7.01 141.63 ± 2.49 0.151
Postoperative 3days      
ALB(g/l) 36.31 ± 5.19 37.03 ± 5.73 0.419
serum sodium (mmol/L) 141.40 ± 6.01 138.34 ± 4.46 0.000**
Postoperative 3months      
ALB(g/l) 39.14 ± 5.68 36.63 ± 4.71 0.003**
serum sodium (mmol/L) 141.03 ± 5.87 138.71 ± 5.65 0.014*
Analysis of perioperative complications and non-perioperative complications
The incidence of 2 Clavien-dindo grade II and above complications was 10.75% in group B-II and compared with 29.23% in group B-IIB ,the difference was statistically signicant..
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Severe postoperative complications occurred for 7 cases (10.7%) of postoperative intestinal obstruction in the two groups and 2 cases (2.1%) of gastric emptying dysfunction in the two groups. The comparison is statistically signicant. The postoperative weight loss at 3 months of the Billroth-II with Braun group and the B-II group both decreased to varying degrees compared with preoperative,the Billroth- Braun reconstruction group was 4.04 ± 1.33kg, which was smaller than 8.08 ± 1.47kg of the Billroth- type reconstruction group, the difference was statistically signicant (p < 0.05)(Table 1). In the follow-up period, there was no death or recurrence of remnant gastric cancer, but some patients had gastric emptying dysfunction, pulmonary infection, abdominal hemorrhage, abdominal wall incisional hernia, postoperative cholecystolithiasis, cholecystitis, and residual gastritis. The chi-square test for complications found no statistical difference. In group B-II, one patient underwent secondary hemostasis treatment due to abdominal hemorrhage during hospitalization, and recovered well after surgery. Four patients were found to have cholecystolithiasis and cholecystitis during routine abdominal ultrasound examination during the postoperative follow-up period, with none special symptoms and treatment. The symptoms of the remaining patients improved signicantly after conservative treatment. In general, B-IIB surgery has advantages over B-II surgery in terms of postoperative complication rates, and the difference is statistically signicant. (Table 4) 
  Table 4
Analysis and comparison of surgical complications projects(n) B-IIB group B-II
group
lung infection 0 0   1
abdominal bleeding 0 1   0.411
postoperative intestinal obstruction 2 7   0.033
abdominal incisional hernia 0 0   1
postoperative enterolithiasis cholecystitis 2 2   1
Remnant gastritis 4 7   0.202
Analysis of PGSAS-45 Questionnaire Survey Data
Comparative analysis demostrated that the mean scores of esophageal reux, dyspepsia and dumping syndrome in the B-IIB group were lower than those in the B-II group at 3 months after surgery, with statistical differences (p = 0.031, p = 0.034, p = 0.037), indicating that patients in the B-IIB group were less affected in life. Other related symptoms were not statistically signicant. (Table 5) 
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  Table 5
Postoperative quality of life survey of patients projects(n) B-II group B-IIB group t/χ2 value p value
Esophageal reux symptoms 2.15 ± 0.85 1.84 ± 0.92 2.177 0.031
Abdominal pain symptoms 1.72 ± 0.55 1.72 ± 0.56 0.03 0.976
Eating discomfort 2.08 ± 0.65 2.22 ± 0.74 -1.222 0.224
Indigestion 2.22 ± 0.91 1.86 ± 1.10 2.142 0.034
Dumping syndrome 2.32 ± 0.94 1.98 ± 1.06 2.103 0.037
Discussion With the increasing incidence of lower gastric cancer and the diagnosis rate of early gastric cancer in recent years, the extent of surgical resection of distal gastric cancer and the reconstruction of the digestive tract have gradually become the focus of gastrointestinal surgeons[13].In the process of diagnosis and treatment of distal gastrectomy for gastric cancer, we usually focus on the incidence of postoperative complications of patients in terms of clinical ecacy[14].In terms of quality of life, gastroesophageal reux, which prevents regular dietary intake, is one of the important factors that signicantly compromise the quality of life of patients during the postoperative period[15].Few reports have compared B-IIB with BII reconstruction. This article discusses the clinical ecacy and quality of life analysis of Braun anastomosis in laparoscopic distal gastrectomy.
B-II is the mainly used reconstruction method of distal gastrectomy. This method provides the advantages of that gastrectomy is not limited by the tension of anastomosis and more gastric bodies can be removed. However, the disadvantage is the consequent changes in anatomy and physiology of gastrojejunostomy, which may cause more complications,…