**2.2. Reconstructive procedures without duodenal passage preservation after total gastrectomy**

### *2.2.1. Esophagojejunostomy Roux-en-Y configuration*

**1. Introduction**

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**1.1. Background and history**

enectomy, and reconstruction.

standard procedure for reconstruction after TG [8].

**2. Reconstructive procedures after total gastrectomy**

**2.1. Concept of reconstructive procedures after total gastrectomy**

The development of stomach surgery is one of the most fascinating chapters in the history of surgery. The era of surgical treatment of gastric cancer (GC) began with the first successfully performed distal subtotal gastrectomy in 1881 by Theodor Billroth. The first total gastrectomy (TG) was probably carried out by Conner in 1887 in Cincinnati, but the patient died [1]. The first successful TG due to GC was performed by Carl Schlatter in Switzerland in 1897 [2]. The patient was a 56-year-old woman who lived less than 14 months and died from secondary metastatic deposits in the liver. Krönlein first introduced the term TG in 1898. Charles Brigham of San Francisco in the same year performed the first successful TG in the United States to create an esophagoduodenal anastomosis, using the Murphy button [3]. The high postoperative mortality in TG performed in the 1940s, was reduced by the introduction of antibiotics, the use of blood transfusions, and the improvement of anesthetics and surgical techniques. During this period TG was proposed as a routine surgical treatment for all resectable GC. This approach was later abandoned due to inability to improve the survival rate, high operative mortality, and increased incidence of undesirable postoperative effects after TG [4]. By 1980, TG was rarely performed and was only applied in highly selective cases [5]. The contribution of these and many other authors during the nineteenth century provided a basis for modern surgical treatment of patients with GC. From the beginning of the 1940s, radical resection, including regional lymphadenectomy for all GC, was recommended [6]. Operations of such extensions, at that time, were burdened with unacceptable morbidity and mortality. To date, efforts have been made to define the optimal extent of resection, lymphad-

Digestive tract reconstruction after TG was mostly performed initially by creating a direct anastomosis of the esophagus with a duodenum or with a jejunum loop. The inevitable problem of billiard regurgitation was solved in 1909 by adopting the creation of the Roux-en-Y (RY) type of esophagojejunostomy configuration [7]. A large number of surgeons continued to perform jejunum loop reconstruction until 1947, when Orr promoted the concept of endto-end anastomosis using the RY-type configuration of esophagojejunostomy, which is now a

During the first successful TG in 1897, Schlatter reconstructed the digestive tract by creating end-to-side esophagojejunostomy [2]. Many of the pioneers of TG performed reconstruction with esophagoduodenostomy or formed loop esophagojejunostomy [7, 9]. High operational risk and frequent malnutrition observed during the postoperative period gave TG an unfavorable reputation. The loop esophagojejunostomy technique was modified by Hoffman in 1922. The RY configuration of esophagojejunostomy has become the most widely used method of reconstructing intestinal continuity around the world [13, 14]. This precious intestinal configuration is now used in reconstruction and drainage of the stomach, esophagus, and pancreatic-biliary tree, as well as in bariatric surgery [15].

The procedure was inaugurated by César Roux (1857–1934), a Swiss surgeon and professor, in 1893 [16]. Initially, after TG, the jejunum loop was placed in a retrocolonic fashion. RY configuration of esophagojejunostomy immediately became objectionable due to a recurrent complication, that is, the potential formation of ulceration on the jejunal anastomosis [7]. The idea of using the RY configuration for reconstruction after TG was introduced early, in 1909 [9]. Despite Reid's 1925 report on the use of this RP, most of the surgeons of that time continued to prefer loop esophagojejunostomy with an anastomosis between two jejunum loops, thereby preventing the alkaline reflux of duodenal content and consecutive esophagitis [17]. In 1940, several papers again drew attention to the Roux-en-Y intestinal configuration, and in 1947, Orr reintroduces end-to-side esophagojejunostomy in creating a RY configuration (**Figures 1**–**3**) [8].

The primary factor in creating RY is the preservation of adequate vascularization. Jejunum vascularization comes from superior mesenteric artery, aorte abdominalis' branch. Superior mesenteric artery branches for vascularization of the intestinum are formed on its left side, and their number is variable 13–21, for vascularization of jejunum 3–7 (average 5) and 8–17 (average 11) for the ileum. Intestinal arteries branch in the mesenterium, and through the

**Figure 1.** Schematic representation of reconstruction after TG without DP with a standard RY configuration with the creation of (A) end-to-side or (B) end-to-end esophagojejunostomy.

vascular arcades of the I–IV orders, they connect to one another before the separation of terminal vasa recta entering the small intestine on the mesenteric edge. Arcades are more developed in the proximal part of the intestinum. They are arranged in three rows, so that arcades allow good vascularization and formation of isolated segments. Vasa recta are terminal type, and each such blood vessel vascularizes about 0.5 cm of the intestinal wall [18]. There are long and short arteriolae rectae. The long arteriole recta are divided into two branches, anterior and posterior. Entering the jejunum wall, each of those branches vascularizes specific area of the jejunum wall and they anastomose on the antimesenteric edge. The antimesenteric edge has the weakest vascularization and therefore is susceptible to the occurrence of dehiscence after the creation of anastomosis. Short arteriolae rectae, which can directly originate from the paraintestinal arterial arcades, or from other arterioles, are intended for the vascularization of the mesenteric intestine [19]. The regularly firmed distal end of the RY

**Figure 3.** A representation of the operative reconstructive technique after TG without the preservation of DP by the RY configuration on the material of the author of this chapter: (E) specimen of the stomach, spleen, and large omentum, (F) formed end-to-end esophagojejunostomy (red arrow), (G) formed end-to-side jejunojejunostomy with Roux Y anastomosis (blue arrow), (H) contrast radiography: sufficient anastomosis of esophagojejunostomy (red line) and end-

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The main goal in choosing the reconstruction of the esophago-intestinal continuity RY configuration after TG without preserving DP is to prevent the formation of biliary reflux into the esophagus. Biliary contents can cause damage to the esophagus mucous membranes, or

jejunum loop was mobilized by dividing two vasa recta [7].

to-side jejunojejunostomy with Roux-en-Y anastomosis (blue line).

**Figure 2.** A representation of the operative reconstructive technique after TG without the preservation of DP by the RY configuration on the material of the author of this chapter: (A) diffuse GC of the antropyloric region of the stomach; (B) closure of the duodenal residue using a linear stapler TA 30; (C) lymphovascular dissection of the plexus coeliacus, a.hepaticae communis (yellow arrow), a.gastricae sin. (red arrow), and a.lienalis (blue arrow); (D) bringing the jejunum loop to the approximation with distal esophagus and forming end-to-end esophagojejunostomy with circular stapler CEEA Ø25 mm.

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**Figure 1.** Schematic representation of reconstruction after TG without DP with a standard RY configuration with the

**Figure 2.** A representation of the operative reconstructive technique after TG without the preservation of DP by the RY configuration on the material of the author of this chapter: (A) diffuse GC of the antropyloric region of the stomach; (B) closure of the duodenal residue using a linear stapler TA 30; (C) lymphovascular dissection of the plexus coeliacus, a.hepaticae communis (yellow arrow), a.gastricae sin. (red arrow), and a.lienalis (blue arrow); (D) bringing the jejunum loop to the approximation with distal esophagus and forming end-to-end esophagojejunostomy with circular stapler

creation of (A) end-to-side or (B) end-to-end esophagojejunostomy.

6 Gastric Cancer - An Update

CEEA Ø25 mm.

**Figure 3.** A representation of the operative reconstructive technique after TG without the preservation of DP by the RY configuration on the material of the author of this chapter: (E) specimen of the stomach, spleen, and large omentum, (F) formed end-to-end esophagojejunostomy (red arrow), (G) formed end-to-side jejunojejunostomy with Roux Y anastomosis (blue arrow), (H) contrast radiography: sufficient anastomosis of esophagojejunostomy (red line) and endto-side jejunojejunostomy with Roux-en-Y anastomosis (blue line).

vascular arcades of the I–IV orders, they connect to one another before the separation of terminal vasa recta entering the small intestine on the mesenteric edge. Arcades are more developed in the proximal part of the intestinum. They are arranged in three rows, so that arcades allow good vascularization and formation of isolated segments. Vasa recta are terminal type, and each such blood vessel vascularizes about 0.5 cm of the intestinal wall [18]. There are long and short arteriolae rectae. The long arteriole recta are divided into two branches, anterior and posterior. Entering the jejunum wall, each of those branches vascularizes specific area of the jejunum wall and they anastomose on the antimesenteric edge. The antimesenteric edge has the weakest vascularization and therefore is susceptible to the occurrence of dehiscence after the creation of anastomosis. Short arteriolae rectae, which can directly originate from the paraintestinal arterial arcades, or from other arterioles, are intended for the vascularization of the mesenteric intestine [19]. The regularly firmed distal end of the RY jejunum loop was mobilized by dividing two vasa recta [7].

The main goal in choosing the reconstruction of the esophago-intestinal continuity RY configuration after TG without preserving DP is to prevent the formation of biliary reflux into the esophagus. Biliary contents can cause damage to the esophagus mucous membranes, or alkaline esophagitis [20]. In 1924, the proposed RY loop length was only 7.5 cm, but it increased steadily and significantly over time. Wells proposed in 1956 a length of 20–25 cm. The smallest length of the RY loop of 35 cm proved to be capable of preventing the formation of alkaline biliary reflux [21]. The vast majority of experienced surgeons today use RY loop length of 40–60 cm. The wide application of the RP RY configuration is attributed to its simplicity because it uses a minimum number of anastomosis.

In order to adequately replace the stomach and increase the reservoir of the jejunal substituent, the RP RY configuration was modified by Hunt and later by Lawrence by creating a jejunal pouch [22, 23]. Several modalities of the reconstruction of the jejunal pouch include forming formations J-pouch, Ω-pouch, S-pouch, and an aboral pouch [22–25].

Forming the Hunt-Lawrence pouch, the jejunum in length is brought up posterior to the transverse colon. The distal portion of the divided afferent limb, with approximate length of 15–20 cm, is placed posterior to the transverse colon, plicated to the proximal efferent limb and retained by traction sutures. A small stab wound is formed at the midportion of each limb of plicated loops, and a linear stapler is introduced through it, while side-to-side anastomoses are created upward and down along the antimesenteric borders. Following the inspection of the anastomotic lines for complete hemostasis, a circular stapler (stapler CEEA) is introduced through the central hole of the pouch for the esophagojejunostomy.

The use of pouch reconstruction provides a reduction in the occurrence of dumping syndrome, postoperative weight development, regurgitation of bile, and insufficient size of indi-

**Figure 5.** A representation of operative reconstructive technique after TG without DP preservation by the pouch configuration on the material of the author of this chapter: (A) end-to-side esophagojejunostomy is formed (red arrow) and longitudinal side-to-side jejunojejunostomy (green arrow); (B) end-to-side jejunojejunostomy is created with Roux-

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The RP using the jejunum after TG with the preservation of DP is the esophagus RY configuration of the DT in the establishment of esophagoduodenal continuity. The description of operational technique was first provided in 1965 by Japanese authors Kajitani and Sato [29]. In this RP after TG, the duodenum in the first act remains open, and after the creation of an esophagojejunal anastomosis according to the principles of the operational technique of carrying RY configurations with a duodenum duct, an additional distal end-to-side jejunoduodenal anastomosis is established at about 20 cm distal from created esophagojejunal anastomosis [30]. Today's modification of the originally described technique is the creation of end-to-end duodenal anastomosis at 35–40 cm distal from esophagojejunal anastomosis [31]. Creation of distal termino-lateral jejunojejunal anastomosis is performed according to the principles of the original RY configuration of esophagojejunostomy at about 60 cm from end-to-side or end-to-end esophagojejunal anastomosis (**Figure 6**). Creation of esophagojejunal anastomosis is performed by a manual two-layer suture technique or the use of the CEEA circular surgical stapler, while the creation of jejunoduodenal and jejunojejunal anastomosis is performed by a manual two-layer suture technique (**Figure 7**) [31, 32]. The RY configuration

**2.3. Reconstructive procedure with duodenal passage preservation after total** 

*2.3.1. Esophagojejunostomy Roux-en-Y double tract configuration*

of the DT is now applied in some institutions in Japan.

*2.3.2. Esophagojejunostomy with the interposition of the jejunal segment by Longmire*

RP using the jejunum after TG with the preservation of DP is the interposition to isoperistaltics free jejunal segment according to the Longmire method in establishing esophagoduodenal

gested meals [27].

en-Y anastomosis (blue arrow).

**gastrectomy**

The hole is closed transversely with a running suture following the withdrawal of the circular stapler. Intestinal continuity is then reestablished by hand in RY fashion, about 20–30 cm below the pouch (**Figures 4** and **5**) [26–28].

**Figure 4.** Schematic representation of reconstruction after TG without DP with a the Hunt-Lawrence pouch.

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**Figure 5.** A representation of operative reconstructive technique after TG without DP preservation by the pouch configuration on the material of the author of this chapter: (A) end-to-side esophagojejunostomy is formed (red arrow) and longitudinal side-to-side jejunojejunostomy (green arrow); (B) end-to-side jejunojejunostomy is created with Rouxen-Y anastomosis (blue arrow).

The use of pouch reconstruction provides a reduction in the occurrence of dumping syndrome, postoperative weight development, regurgitation of bile, and insufficient size of indigested meals [27].
