**1. Introduction**

#### **1.1. Background and history**

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, lymphadenectomy, and reconstruction.

He added a small side-to-side jejunojejunostomy between two ends of the jejunum loop [10]. This provided partial bypass to the duodenal content and reduced the frequency of alkaline reflux esophagitis. The major immediate postoperative problem after TG concerned the integrity of anastomosis on the esophagus. Later postoperative problems were associated with reconstruction and nutritional status and quality of life that is more affected by the aspects of

Reconstructive Procedures after Total Gastrectomy for Gastric Cancer

http://dx.doi.org/10.5772/intechopen.75591

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To date, more than 60 different reconstructive procedures (RP) of intestinal reconstructions have been described after TG which were, and are now, in use in surgical institutions [11, 12]. The main modalities of reconstruction after TG are restoration of intestinal continuity, without preserving duodenal passage (DP) of food (esophagojejunostomy with RY configuration) and restoration of intestinal continuity with the preservation of DP (esophagojejunostomy with RY configuration and formation of side-to-end jejunoduodenostomy double tract (DT) and Longmire's longitudinal interposition). Operations in these categories can be combined with the formation of an enteral pouch or a gastric reservoir that simulates the function of the reservoir of the normal intact stomach. The RP with pouch and neo-stomach formation have been developed to provide food tanks, with the goal of preserving duodenal transit and providing the anatomy and physiology of the digestive tract. Advantages and disadvantages of these RP continue to be the subject of discussion due to the existence of contradictory results from various studies.

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

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 pan-

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

reconstruction than the anastomosis on the esophagus itself.

*2.2.1. Esophagojejunostomy Roux-en-Y configuration*

creatic-biliary tree, as well as in bariatric surgery [15].

**gastrectomy**

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 standard procedure for reconstruction after TG [8].
