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Ohmura et al. Mini-invasive Surg 2019;3:4  I  http://dx.doi.org/10.20517/2574-1225.2018.69                                      Page 7 of 13


                                             Surgically resected gastric cancer patients
                                                    (Sep.2008-Dec.2017)
                                                        N = 452
                                                                              Open surgery
                                                                               n = 229
                                                 Laparoscopic surgery
                                                     n = 223
                                                                          Total gastrectomy (n = 21)
                                                                          Proximal gastrectomy (n = 3)
                                                  Distal gastrectomy
                                                     n = 199
                                                                              Colectomy (n = 3)
                                                                             Nephrectomy (n = 1)
                                                  Enrolled patients
                                                      n = 195
                                                 Anastomotic procedure


                                 Hand-sewn via small laparotomy  Intracorporeal HHS technique
                                          n = 85                   n = 110

                          Figure 4. Flow chart for the current study detailing inclusion and exclusion criteria; HHS: hemi-hand-sewn

               time was longer in the IC-HHS group (276.4 min) than in the EC-THS group (234.6 min) (P = 0.04) and
               intraoperative blood loss was smaller in IC-HHS group (26.3 mL) compared to EC-THS group (48.9 mL)
               (P < 0.01). R0 resection was achieved in all patients with free surgical margin defined by pathological
               examination.


               Postoperative outcome
               Surgical site infection was observed at the epigastric wound in the EC-THS group (5 cases) and at the
               umbilical wound in the IC-HHS group (1 case). Laparoscopic cholecystectomy was required in one case
               of the IC-HHS group due to necrotic cholecystitis resistant to conservative treatment on day 9 after
               gastrectomy. One case of delayed gastric emptying was observed in the EC-THS group. The frequency of
               intra-abdominal abscess or pancreatic fistula development in the EC-THS and IC-HHS group were 3.5%
               and 1.8%, respectively and they were all cured by administration of antibiotics. One case of postoperative
               pneumonia in the EC-THS group was also successfully treated by antibiotics.


               Evaluation of resected specimen
               Table 2 shows the measured length of each part of the resected specimens. The greater curvature of the IC-
               HHS group was significantly longer than that of EC-THS group (214.6 vs. 228.7 mm, P < 0.01). The length of
               the lesser curvature and the duodenum were not significantly different. There was no correlation between
               BMI and the length of the greater curvature in the IC-HHS group (r = 0.03, P = 0.47), while in the EC-HS
               group, the length of the greater curvature weakly correlated with BMI (r = -0.44, P < 0.01). The length of
               the great curvature of the resected stomach tends to be shorter as BMI increases [Figure 5A and B].


               DISCUSSION
               This study found that the IC-HHS technique for laparoscopic B-I gastroduodenostomy was successfully
               accomplished in all 110 cases without any procedure-specific complications, indicating its technical
               feasibility. The average operation time was about 40 min longer than EC-THS reconstruction. The similar
               difference in the subgroup analysis in D1+ cases suggested that the extended operation time was due to
               the difference in the anastomotic procedures. Anastomotic leakage and stricture were not observed in our
               experiences.
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