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Table 1. Summary of different methods applied in intracorporeal Billroth-I reconstruction
Year Author No. Age Method Anastomotic Operative Blood loss Postoperative Anastomosis-
time (min) time (min) stay (d) related
complations
Hand-sewn anastomosis in intracorporeal B-I
reconstruction
2003 Takiguchi et al. [6] 1 50 Hand-sewn 90 420 NS 7 0
2012 Matsuo et al. [7] 18 NS Hand-sewn 64.6 NS 53.1 ± 91 21.7 0
Circular stapler used in intracorporeal B-I
reconstruction
1995 Uyama et al. [8] 1 56 CS NS 318 NS 14 0
2012 Kim et al. [13] 23 60.3 ± 11.3 CS 43.3 ± 15.4 209.7 ± 49.9 72.6 ± 47.9 7.7 ± 2.3 0
2012 Omori et al. [15] 20 NS CS NS 279 NS 9 0
Linear stapler intracorporeal B-I reconstruction
2011 Kanaya et al. [17] 100 65.5 ± 9.3 DA 13.0 ± 3.9 239.2 ± 53.2 92.6 ± 89.7 16.7 ± 13.8 1 (anastomotic leak)
2014 Okabe et al. [20] 185 NS DA NS 283 NS NS 5 (anastomotic leak)
3 (delayed gastric
emptying)
2011 Noshiro et al. [19] 71 70 ± 10 DA NS 260 ± 56 63 ± 79 NS 6 (anastomotic leak)
2014 Huang et al. [22] 102 60 ± 12 Modified DA 12.2 ± 4.2 150.6 ± 30.2 48.2 ± 33.2 12.0 ± 6.5 2 (anastomotic leak)
2008 Tanimura et al. [24] 196 NS TST 28 ± 4 249 ± 38 NS NS 1 (anastomotic leak)
2013 Ikeda et al. [25] 9 59.3 BBT 34 ± 7 255 ± 13 50 ± 66 14.2 ± 2.3 0
2016 Byun et al. [26] 190 57.2 ± 12.5 LSGD NS 147.9 ± 49.4 97.3 ± 95.7 6.8 ± 3.1 2 (anastomotic
stenosis)
2018 Fukunaga et al. [27] 160 69.5 ± 10 ART NS 227 ± 75 47.3 ± 50 12 ± 5 0

CS: Circular stapler; DA: delta-shaped anastomosis; TST: triangulating stapling technique; BBT: book-binding technique; LGSD: linear-
shaped gastroduodenostomy; ART: augmented rectangle technique; NS: not stated

end of the duodenal stump was rotated externally by 90°. After the initial suturing between the remnant
stomach and the duodenum, the two sides (posterior wall and cranial wall), the posterior wall and caudal
wall, form a V-shape. A 30 mm linear stapler was applied to close the insertion holes up to the closest
side of the duodenal resection margin. After gastric and duodenal resection margins were ensured to be
close together, the 60 mm laparoscopic linear stapler was used to transect the duodenal resection margin
to create the margin. After the above steps, all the previous linear staplers were removed from duodenal
resection margin.

Thanks to the elimination of the stay sutures in the anastomosis site, the risk of leakage of the intestinal
contents into the peritoneal cavity can be reduced with a result of reduced incidence of peritoneal
abscess [28,29] . Removing the staple line of the duodenal stump without creating a T-shaped anastomotic
region can avoid postoperative stenosis. The ART can create larger 4-sided anastomosis diameters than
3-sided ones, without worrying about whether the width of the opening will be reduced by the final stapling.

APPLICATION OF BARBED SUTURE IN INTRACORPOREAL ANASTOMOSES
Intracorporeal suturing and knot typing in some B-I anastomosis were time-consuming and tedious and
especially these procedures were the last steps to do in LDG. But various devices have been developed
to simplify the placement of intracorporeal sutures, and barbed suture is one such device. Using the
barber suture could reduce the number of knot typing, the suturing efficiency and reduce the cost of
[30]
[30]
intracorporeal reconstruction with staplers . Lee et al. used barber sutures to close entry hole in 354
patients instead of staplers with a result of minimizing the suturing time. There were no patients who
needed to be converted to usual sutures or mechanical closure with staplers and only one patient presented
with postoperative anastomotic bleeding.

CONCLUSION
Several reconstruction techniques are possible after TLDG [Table 1]. The best reconstruction is the one,
that simplifies the technique, maintains satisfactory nutritional status and quality of life while keeping