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

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

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

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 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

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

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

forming formations J-pouch, Ω-pouch, S-pouch, and an aboral pouch [22–25].

through the central hole of the pouch for the esophagojejunostomy.

because it uses a minimum number of anastomosis.

8 Gastric Cancer - An Update

below the pouch (**Figures 4** and **5**) [26–28].

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 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

**Figure 6.** Schematic representation of reconstruction after TG with DP with a RY configuration of DT with the creation of end-to-end esophagojejunostomy and side-to-end jejunoduodenostomy.

continuity. After Seo's first attempt in 1941, the inauguration of this RP after TG was performed by Longmire in 1951, even though the idea was proposed 3 years earlier by Saccharow [33–36].

Hays interposed a triple jejunal pouch between the esophagus and duodenum in 1953 [37]. Gütgemann recommended the interposition of a very long jejunum loop of at least 30 cm in length to increase the reservoir function of the inserted jejunal pouch [38]. Poth in 1966 favored the interposition of an antiperistaltic jejunal pouch in various combinations [39]. In 1972, Schrader and Koslowski interposed an additional 10 cm shorter antiperistaltic jejuna segment, which anastomosed distally from Longmire's reconstruction [40]. They favored the view that a short anisoperistaltic interposition of the neuromuscular segment could slow down the gastric emptying and simulate neopylorus [40, 41]. In 1982, Cuschieri created a large jejunum pouch interposed between the esophagus and the duodenum [42]. Nakane and Schwarz recommended Hunt-Lawrence Shaped pouch in 1990, interposed between the esophagus and duodenum [27, 43]. The reconstruction of the ileocecal interposition described by Lee and Hunnicutt is also in use with the basic idea of replacing the ileocecal valve as a substitute for the cardiac sphincter [44, 45]. This reconstruction provides anatomic barrier between the neo-stomach and the esophagus to prevent biliopancreatic reflux.

The original RP after TG by Longmire implies the establishment of an esophagoduodenal continuity using a previously fully mobilized intestinal segment on a free vascular sponge ante- or in a retrocolonic fashion by using an isolated first jejunal segment of 15 cm in length (**Figure 8**) [34].

This type of reconstruction is also known as the Beal-Longmire operation. Today, after the mobilization of the first segment of the jejunum in the length of at least 25–35 cm and with a longer

**Figure 8.** Original schematic representation of reconstruction after TG with DP by Longmire [34].

**Figure 7.** A representation of the operative reconstructive technique after TG with the preservation of DP by the RY configuration on the material of the author of this chapter: (A) specimen of the stomach (stomach open by large curvature), spleen, and large omentum, (B) arterial variation of branching a.hepaticae sinistrae accessoriae (yellow arrow) from a.gastricae sinistrae (white arrow), (C) formed end-to-end esophagojejunostomy (red arrow) and side-toend jejunoduodenostomy (yellow arrow), (D) contrast radiography: sufficient anastomosis of esophagojejunostomy (red

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line), jejunoduodenostomy (yellow line), and jejunojejunostomy with Roux-en-Y anastomosis (blue line).

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**Figure 7.** A representation of the operative reconstructive technique after TG with the preservation of DP by the RY configuration on the material of the author of this chapter: (A) specimen of the stomach (stomach open by large curvature), spleen, and large omentum, (B) arterial variation of branching a.hepaticae sinistrae accessoriae (yellow arrow) from a.gastricae sinistrae (white arrow), (C) formed end-to-end esophagojejunostomy (red arrow) and side-toend jejunoduodenostomy (yellow arrow), (D) contrast radiography: sufficient anastomosis of esophagojejunostomy (red line), jejunoduodenostomy (yellow line), and jejunojejunostomy with Roux-en-Y anastomosis (blue line).

continuity. After Seo's first attempt in 1941, the inauguration of this RP after TG was performed by Longmire in 1951, even though the idea was proposed 3 years earlier by Saccharow [33–36]. Hays interposed a triple jejunal pouch between the esophagus and duodenum in 1953 [37]. Gütgemann recommended the interposition of a very long jejunum loop of at least 30 cm in length to increase the reservoir function of the inserted jejunal pouch [38]. Poth in 1966 favored the interposition of an antiperistaltic jejunal pouch in various combinations [39]. In 1972, Schrader and Koslowski interposed an additional 10 cm shorter antiperistaltic jejuna segment, which anastomosed distally from Longmire's reconstruction [40]. They favored the view that a short anisoperistaltic interposition of the neuromuscular segment could slow down the gastric emptying and simulate neopylorus [40, 41]. In 1982, Cuschieri created a large jejunum pouch interposed between the esophagus and the duodenum [42]. Nakane and Schwarz recommended Hunt-Lawrence Shaped pouch in 1990, interposed between the esophagus and duodenum [27, 43]. The reconstruction of the ileocecal interposition described by Lee and Hunnicutt is also in use with the basic idea of replacing the ileocecal valve as a substitute for the cardiac sphincter [44, 45]. This reconstruction provides anatomic barrier

**Figure 6.** Schematic representation of reconstruction after TG with DP with a RY configuration of DT with the creation

of end-to-end esophagojejunostomy and side-to-end jejunoduodenostomy.

between the neo-stomach and the esophagus to prevent biliopancreatic reflux.

(**Figure 8**) [34].

10 Gastric Cancer - An Update

The original RP after TG by Longmire implies the establishment of an esophagoduodenal continuity using a previously fully mobilized intestinal segment on a free vascular sponge ante- or in a retrocolonic fashion by using an isolated first jejunal segment of 15 cm in length

This type of reconstruction is also known as the Beal-Longmire operation. Today, after the mobilization of the first segment of the jejunum in the length of at least 25–35 cm and with a longer

**Figure 8.** Original schematic representation of reconstruction after TG with DP by Longmire [34].

mesentery, both of these structures have retrocolonic transmesocolic position and they make anastomosis with the esophagus and duodenum in the isoperistaltic position. Modification by Schreiber and Gütgemann uses the jejunum segment in a length of 40 cm [38, 46]. Creating a proximal termino-lateral or end-to-end esophagojejunostomy is performed by a manual duallayer technique or the use of a circular stapler (stapler CEEA), while a distal end-to-end jejunoduodenostomy is performed by a manual two-layer mint technique. It is very important that the torsion and tension of the mesenterium be avoided in creating an isolated jejunum segment. The continuity of the resected proximal end of the first segment and the second segment of the jejunum with the application of a two-layer manual knot tying technique is established with endto-end jejunojejunostomy (**Figures 9** and **10**).

In 1952, Longmire and Beal stated that all patients with reconstructed isolated jejunal segment after 4 months of follow-up were able to restore regular nutrition and preoperative body weight. In all patients, there was no early onset of pyrosis and epigastric pain [34]. Longmire also states that after adequate mobilization of the duodenum and avoidance of tension on the esophageal and jejunoduodenal anastomosis itself and the normalization of food passage through the duodenal segment, the benefits of interposition with the jejunal segment have been achieved: increasing the capacity of the isolated jejunal segment with the dilatation of the intestinal wall itself and the smaller regurgitation of biliary and intestinal contents [34]. Longmire points out that with this RP, there was no significant increase in operative risk during the performance of total gastrectomy, that is, the risks of vascular ischemia that are present in the transposition of the ileum and ascendant colon were eliminated. The reconstruction

of the intestinal continuity with the Longmire's jejunal interposition provides theoretical

**Figure 10.** A representation of the operative reconstructive technique after TG with the preservation of DP by Longmire on the material of the author of this chapter: (A) isolated free jejunal segment on the vascular retina placed in a retrocolonic fashion, (B) formed end-to-end esophagojejunostomy (red arrow) and end-to-end jejunoduodenostomy (yellow arrow), (C) formed end-to-end jejunojejunostomy, (D) contrast radiography: sufficient anastomosis of esophagojejunostomy

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The survival rate after TG in GC has been improved thanks to early diagnostics and advanced operating techniques. Many reconstructive techniques after TG have been developed in efforts to prevent postgastrectomy syndrome and preserve the physiological nutritional status of patients and rapid return to normal daily preoperative activities [47]. At the same time, the procedure for gastric reconstruction should be technically easily performed with minimal postoperative complications. RP that meet these requirements are those with the preservation of DP RY configuration of DT, Longmire procedure for the esophagus interposition of the jejunal segment, as well as the procedure of interposition with the jejunal pouch (e.g., Hunt-

advantages over the reconstruction of the RY configuration [31].

**duodenal passage after total gastrectomy**

(red line) and jejunoduodenal anastomosis (yellow line).

Lawrence pouch) [31].

**3. Advantages of reconstructive procedures with preservation** 

**Figure 9.** Schematic representation of reconstruction after TG with DP by Longmire, by interposition of jejunal segment with the creation of end-to-end esophagojejunostomy and end-to-end jejunoduodenostomy.

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mesentery, both of these structures have retrocolonic transmesocolic position and they make anastomosis with the esophagus and duodenum in the isoperistaltic position. Modification by Schreiber and Gütgemann uses the jejunum segment in a length of 40 cm [38, 46]. Creating a proximal termino-lateral or end-to-end esophagojejunostomy is performed by a manual duallayer technique or the use of a circular stapler (stapler CEEA), while a distal end-to-end jejunoduodenostomy is performed by a manual two-layer mint technique. It is very important that the torsion and tension of the mesenterium be avoided in creating an isolated jejunum segment. The continuity of the resected proximal end of the first segment and the second segment of the jejunum with the application of a two-layer manual knot tying technique is established with end-

In 1952, Longmire and Beal stated that all patients with reconstructed isolated jejunal segment after 4 months of follow-up were able to restore regular nutrition and preoperative body weight. In all patients, there was no early onset of pyrosis and epigastric pain [34]. Longmire also states that after adequate mobilization of the duodenum and avoidance of tension on the esophageal and jejunoduodenal anastomosis itself and the normalization of food passage through the duodenal segment, the benefits of interposition with the jejunal segment have been achieved: increasing the capacity of the isolated jejunal segment with the dilatation of the intestinal wall itself and the smaller regurgitation of biliary and intestinal contents [34]. Longmire points out that with this RP, there was no significant increase in operative risk during the performance of total gastrectomy, that is, the risks of vascular ischemia that are present in the transposition of the ileum and ascendant colon were eliminated. The reconstruction

**Figure 9.** Schematic representation of reconstruction after TG with DP by Longmire, by interposition of jejunal segment

with the creation of end-to-end esophagojejunostomy and end-to-end jejunoduodenostomy.

to-end jejunojejunostomy (**Figures 9** and **10**).

12 Gastric Cancer - An Update

**Figure 10.** A representation of the operative reconstructive technique after TG with the preservation of DP by Longmire on the material of the author of this chapter: (A) isolated free jejunal segment on the vascular retina placed in a retrocolonic fashion, (B) formed end-to-end esophagojejunostomy (red arrow) and end-to-end jejunoduodenostomy (yellow arrow), (C) formed end-to-end jejunojejunostomy, (D) contrast radiography: sufficient anastomosis of esophagojejunostomy (red line) and jejunoduodenal anastomosis (yellow line).

of the intestinal continuity with the Longmire's jejunal interposition provides theoretical advantages over the reconstruction of the RY configuration [31].
