Langenbeck's Archives of Surgery

, Volume 402, Issue 6, pp 995–1002 | Cite as

Laparoscopic proximal gastrectomy with oblique jejunogastrostomy

  • Kimitaka Tanaka
  • Yuma EbiharaEmail author
  • Yo Kurashima
  • Yoshitsugu Nakanishi
  • Toshimichi Asano
  • Takehiro Noji
  • Soichi Murakami
  • Toru Nakamura
  • Takahiro Tsuchikawa
  • Keisuke Okamura
  • Toshiaki Shichinohe
  • Satoshi Hirano
How-I-Do-It Article



Proximal early gastric cancer is a good indication for totally laparoscopic proximal gastrectomy (TLPG) with double-tract reconstruction (DTR). However, when most of the dietary intake passes through the escape route of the jejunum, the functional benefits of proximal gastrectomy might be similar to those after total gastrectomy. Our DTR procedure was improved for easy passage through the remnant stomach. The purposes of this study were to present a novel technique for intracorporeal DTR using linear staplers after TLPG and to investigate surgical outcomes.


DTR was performed using linear staplers only. A side-to-side jejunogastrostomy with twisting of both the remnant stomach and the anal jejunum was performed for the purpose of passing meals through the remnant stomach (an oblique jejunogastrostomy technique). The ten patients who underwent TLPG with DTR from January 2011 to August 2016 in Hokkaido University Hospital were retrospectively reviewed. Their clinicopathological characteristics and surgical and postoperative outcomes were collected and analyzed.


The median duration of operation was 285 (range 146–440) min. No patients required blood transfusions. The number of dissected lymph nodes was 32 (range 22–56). There were no intraoperative complications, and no cases were converted to open surgery. All the patients were pT1N0M0 stage IA. No anastomotic leakage or complications were detected. Postoperative gastrography after reconstruction showed that contrast medium flowed mainly to the remnant stomach. The average percentage body weight loss was 14.0 ± 7.1% at 10 months. The average percentage decrease in serum hemoglobin was 5.4 ± 10.4% at 12 months.


This novel technique for intracorporeal DTR provided a considerable advantage by the passage of dietary intake to the remnant stomach after LPG.


Proximal gastrectomy Double-tract reconstruction Gastric cancer Laparoscopic surgery 


Authors’ contributions

Study conception and design: Kimitaka Tanaka, Yuma Ebihara, Yo Kurashima, and Satoshi Hirano; acquisition of data: Kimitaka Tanaka, Yuma Ebihara, and Yo Kurashima; drafting of manuscript: Kimitaka, Tanaka, Yuma Ebihara, and Satoshi Hirano; and critical revision of manuscript: Yuma Ebihara, Yo Kurashima, Yoshitsugu Nakanishi, Toshimichi Asano, Takehiro Noji, Soichi Murakami, Toru Nakamura, Takahiro Tsuchikawa, Keisuke Okamura, Toshiaki Shichinohe, and Satoshi Hirano

Compliance with ethical standards


This study received no funding.

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Supplementary material

423_2017_1587_MOESM1_ESM.mp4 (57 mb)
ESM 1 (MP4 58,318 kb)


  1. 1.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65(2):87–108. doi: 10.3322/caac.21262 CrossRefPubMedGoogle Scholar
  2. 2.
    Sano T, Hollowood A (2006) Early gastric cancer: diagnosis and less invasive treatments. Scand J Surg 95(4):249–255CrossRefPubMedGoogle Scholar
  3. 3.
    Asaka M, Mabe K, Matsushima R, Tsuda M (2015) Helicobacter pylori eradication to eliminate gastric cancer: the Japanese strategy. Gastroenterol Clin N Am 44(3):639–648. doi: 10.1016/j.gtc.2015.05.010 CrossRefGoogle Scholar
  4. 4.
    Jeong O, Park YK (2011) Clinicopathological features and surgical treatment of gastric cancer in South Korea: the results of 2009 nationwide survey on surgically treated gastric cancer patients. J Gastric Cancer 11(2):69–77. doi: 10.5230/jgc.2011.11.2.69 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kim YI, Kim SY, Cho SJ, Park JH, Choi IJ, Lee YJ, Lee EK, Kook MC, Kim CG, Ryu KW, Kim YW (2014) Long-term metformin use reduces gastric cancer risk in type 2 diabetics without insulin treatment: a nationwide cohort study. Aliment Pharmacol Ther 39(8):854–863. doi: 10.1111/apt.12660 CrossRefPubMedGoogle Scholar
  6. 6.
    Kawamura H, Okada K, Isizu H, Masuko H, Yamagami H, Honma S, Ueki S, Noguchi K, Kondo Y (2008) Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure. Surg Endosc 22(1):81–85. doi: 10.1007/s00464-007-9373-y CrossRefPubMedGoogle Scholar
  7. 7.
    Ebihara Y, Okushiba S, Kawarada Y, Kitashiro S, Katoh H (2013) Outcome of functional end-to-end esophagojejunostomy in totally laparoscopic total gastrectomy. Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie 398(3):475–479. doi: 10.1007/s00423-013-1051-z CrossRefGoogle Scholar
  8. 8.
    Takiguchi N, Takahashi M, Ikeda M, Inagawa S, Ueda S, Nobuoka T, Ota M, Iwasaki Y, Uchida N, Kodera Y, Nakada K (2015) Long-term quality-of-life comparison of total gastrectomy and proximal gastrectomy by postgastrectomy syndrome assessment scale (PGSAS-45): a nationwide multi-institutional study. Gastric Cancer 18(2):407–416. doi: 10.1007/s10120-014-0377-8 CrossRefPubMedGoogle Scholar
  9. 9.
    Nozaki I, Hato S, Kobatake T, Ohta K, Kubo Y, Kurita A (2013) Long-term outcome after proximal gastrectomy with jejunal interposition for gastric cancer compared with total gastrectomy. World J Surg 37(3):558–564. doi: 10.1007/s00268-012-1894-4 CrossRefPubMedGoogle Scholar
  10. 10.
    Ichikawa D, Komatsu S, Kubota T, Okamoto K, Shiozaki A, Fujiwara H, Otsuji E (2014) Long-term outcomes of patients who underwent limited proximal gastrectomy. Gastric Cancer 17(1):141–145. doi: 10.1007/s10120-013-0257-7 CrossRefPubMedGoogle Scholar
  11. 11.
    Papachristou DN, Fortner JG (1980) Adenocarcinoma of the gastric cardia. The choice of gastrectomy. Ann Surg 192(1):58–64CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Yoo CH, Sohn BH, Han WK, Pae WK (2004) Long-term results of proximal and total gastrectomy for adenocarcinoma of the upper third of the stomach. Cancer Res Treat 36(1):50–55. doi: 10.4143/crt.2004.36.1.50 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Wen L, Chen XZ, Wu B, Chen XL, Wang L, Yang K, Zhang B, Chen ZX, Chen JP, Zhou ZG, Li CM, Hu JK (2012) Total vs. proximal gastrectomy for proximal gastric cancer: a systematic review and meta-analysis. Hepato-Gastroenterology 59(114):633–640. doi: 10.5754/hge11834 PubMedGoogle Scholar
  14. 14.
    Pu YW, Gong W, Wu YY, Chen Q, He TF, Xing CG (2013) Proximal gastrectomy versus total gastrectomy for proximal gastric carcinoma. A meta-analysis on postoperative complications, 5-year survival, and recurrence rate. Saudi Med J 34(12):1223–1228PubMedGoogle Scholar
  15. 15.
    Uyama I, Ogiwara H, Takahara T, Kikuchi K, Iida S (1995) Laparoscopic and minilaparotomy proximal gastrectomy and esophagogastrostomy: technique and case report. Surgical laparoscopy & endoscopy 5(6):487–491Google Scholar
  16. 16.
    Uyama I, Sugioka A, Fujita J, Komori Y, Matsui H, Hasumi A (2000) Completely laparoscopic proximal gastrectomy with jejunal interposition and lymphadenectomy. J Am Coll Surg 191(1):114–119CrossRefPubMedGoogle Scholar
  17. 17.
    Ahn SH, do Jung H, Son SY, Lee CM, do Park J, Kim HH (2014) Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer. Gastric Cancer 17(3):562–570. doi: 10.1007/s10120-013-0303-5 CrossRefPubMedGoogle Scholar
  18. 18.
    Aikou T, Natsugoe S, Shimazu H, Nishi M (1988) Antrum preserving double tract method for reconstruction following proximal gastrectomy. Jpn J Surg 18(1):114–115CrossRefPubMedGoogle Scholar
  19. 19.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Nakajima T (2002) Gastric cancer treatment guidelines in Japan. Gastric Cancer 5(1):1–5. doi: 10.1007/s101200200000 CrossRefPubMedGoogle Scholar
  21. 21.
    Japanese Gastric Cancer A (1998) Japanese classification of gastric carcinoma—2nd English edition. Gastric Cancer 1(1):10–24. doi: 10.1007/s101209800016 CrossRefGoogle Scholar
  22. 22.
    Matsui H, Uyama I, Sugioka A, Fujita J, Komori Y, Ochiai M, Hasumi A (2002) Linear stapling forms improved anastomoses during esophagojejunostomy after a total gastrectomy. Am J Surg 184(1):58–60CrossRefPubMedGoogle Scholar
  23. 23.
    Kumagai K, Shimizu K, Yokoyama N, Aida S, Arima S, Aikou T, Japanese Society for the Study of Postoperative Morbidity after Gastrectomy (2012) Questionnaire survey regarding the current status and controversial issues concerning reconstruction after gastrectomy in Japan. Surg Today 42(5):411–418. doi: 10.1007/s00595-012-0159-z CrossRefPubMedGoogle Scholar
  24. 24.
    Katsoulis IE, Robotis JF, Kouraklis G, Yannopoulos PA (2006) What is the difference between proximal and total gastrectomy regarding postoperative bile reflux into the oesophagus? Dig Surg 23(5–6):325–330. doi: 10.1159/000097948 PubMedGoogle Scholar
  25. 25.
    An JY, Youn HG, Choi MG, Noh JH, Sohn TS, Kim S (2008) The difficult choice between total and proximal gastrectomy in proximal early gastric cancer. Am J Surg 196(4):587–591. doi: 10.1016/j.amjsurg.2007.09.040 CrossRefPubMedGoogle Scholar
  26. 26.
    Katai H, Morita S, Saka M, Taniguchi H, Fukagawa T (2010) Long-term outcome after proximal gastrectomy with jejunal interposition for suspected early cancer in the upper third of the stomach. Br J Surg 97(4):558–562. doi: 10.1002/bjs.6944 CrossRefPubMedGoogle Scholar
  27. 27.
    Kinoshita T, Gotohda N, Kato Y, Takahashi S, Konishi M, Kinoshita T (2013) Laparoscopic proximal gastrectomy with jejunal interposition for gastric cancer in the proximal third of the stomach: a retrospective comparison with open surgery. Surg Endosc 27(1):146–153. doi: 10.1007/s00464-012-2401-6 CrossRefPubMedGoogle Scholar
  28. 28.
    Nakamura M, Nakamori M, Ojima T, Katsuda M, Iida T, Hayata K, Matsumura S, Kato T, Kitadani J, Iwahashi M, Yamaue H (2014) Reconstruction after proximal gastrectomy for early gastric cancer in the upper third of the stomach: an analysis of our 13-year experience. Surgery 156(1):57–63. doi: 10.1016/j.surg.2014.02.015 CrossRefPubMedGoogle Scholar
  29. 29.
    Nomura E, Lee SW, Kawai M, Yamazaki M, Nabeshima K, Nakamura K, Uchiyama K (2014) Functional outcomes by reconstruction technique following laparoscopic proximal gastrectomy for gastric cancer: double tract versus jejunal interposition. World J Surg Oncol 12:20. doi: 10.1186/1477-7819-12-20 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Hong J, Qian L, Wang YP, Wang J, Hua LC, Hao HK (2015) A novel method of delta-shaped intracorporeal double-tract reconstruction in totally laparoscopic proximal gastrectomy. Surg Endosc. doi: 10.1007/s00464-015-4490-5
  31. 31.
    Yang K, Bang HJ, Almadani ME, Dy-Abalajon DM, Kim YN, Roh KH, Lim SH, Son T, Kim HI, Noh SH, Hyung WJ (2016) Laparoscopic proximal gastrectomy with double-tract reconstruction by intracorporeal anastomosis with linear staplers. J Am Coll Surg. doi: 10.1016/j.jamcollsurg.2016.01.002
  32. 32.
    Davis JL, Selby LV, Chou JF, Schattner M, Ilson DH, Capanu M, Brennan MF, Coit DG, Strong VE (2016) Patterns and predictors of weight loss after gastrectomy for cancer. Ann Surg Oncol 23(5):1639–1645. doi: 10.1245/s10434-015-5065-3 CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Ohashi M, Morita S, Fukagawa T, Oda I, Kushima R, Katai H (2015) Functional advantages of proximal gastrectomy with jejunal interposition over total gastrectomy with Roux-en-Y esophagojejunostomy for early gastric cancer. World J Surg 39(11):2726–2733. doi: 10.1007/s00268-015-3180-8 CrossRefPubMedGoogle Scholar
  34. 34.
    Nishigori T, Okabe H, Tsunoda S, Shinohara H, Obama K, Hosogi H, Hisamori S, Miyazaki K, Nakayama T, Sakai Y (2017) Superiority of laparoscopic proximal gastrectomy with hand-sewn esophagogastrostomy over total gastrectomy in improving postoperative body weight loss and quality of life. Surg Endosc. doi: 10.1007/s00464-016-5403-y
  35. 35.
    Iwahashi M, Nakamori M, Nakamura M, Naka T, Ojima T, Iida T, Katsuda M, Ueda K, Yamaue H (2009) Evaluation of double tract reconstruction after total gastrectomy in patients with gastric cancer: prospective randomized controlled trial. World J Surg 33(9):1882–1888. doi: 10.1007/s00268-009-0109-0 CrossRefPubMedGoogle Scholar
  36. 36.
    Nomura E, Lee SW, Tokuhara T, Nitta T, Kawai M, Uchiyama K (2013) Functional outcomes according to the size of the gastric remnant and the type of reconstruction following distal gastrectomy for gastric cancer: an investigation including total gastrectomy. Jpn J Clin Oncol 43(12):1195–1202. doi: 10.1093/jjco/hyt141 CrossRefPubMedGoogle Scholar
  37. 37.
    Zhou D, Liu QX, Deng XF, Min JX, Dai JG (2015) Comparison of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis. J Cardiothorac Surg 10:67. doi: 10.1186/s13019-015-0271-4 CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, Wada Y, Ohtoshi M (2002) Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg 195(2):284–287CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Kimitaka Tanaka
    • 1
  • Yuma Ebihara
    • 1
    Email author
  • Yo Kurashima
    • 1
  • Yoshitsugu Nakanishi
    • 1
  • Toshimichi Asano
    • 1
  • Takehiro Noji
    • 1
  • Soichi Murakami
    • 1
  • Toru Nakamura
    • 1
  • Takahiro Tsuchikawa
    • 1
  • Keisuke Okamura
    • 1
  • Toshiaki Shichinohe
    • 1
  • Satoshi Hirano
    • 1
  1. 1.Department of Gastroenterological Surgery IIHokkaido University Graduate School of MedicineSapporoJapan

Personalised recommendations