Proximate

All surgeries, including laparoscopic surgery and open surgery, were performed by one group, including two experienced senior surgeons (who are experts in gastrointestinal surgery), two junior surgeons, and two residents.
In laparoscopic procedures, the carbon dioxide pneumoperitoneum pressure was kept at 12 mmHg. Stapled anastomose was constructed in a side-to-side fashion using a 60 mm linear stapler (ECHELON FLEX Ethicon Endo-Surgery LLC, Guaynabo, USA). After resection and stapled anastomosis, we regularly reinforced the anastomosis with absorbable sutures. Generally, the surgery was finished in a totally laparoscopic procedure. Hand-assisted anastomosis was needed to make ensure the quality of anastomosis, when the risk of laparoscopic anastomosis was high.
In open procedures, we had a side-to-side anastomosis using a 75 mm linear cutter stapler (PROXIMATE, Ethicon Endo-Surgery LLC, Guaynabo, USA), and we reinforced the anastomosis with absorbable sutures routinely.

All patients had undergone LADG with D2 lymphadenectomy, which was performed as described previously (22 (link), 23 (link)). After LADG and closure of the duodenal stump, side-to-side anastomosis was performed between the remnant stomach and jejunum, 30 cm from the ligament of Treitz. Next, side-to-side anastomosis between the jejunum, ~35 cm from the gastrojejunostomy, and the jejunum, ~5 cm from the ligament of Treitz, was performed. The afferent loop 3 cm from the gastrojejunostomy anastomosis was closed using three applications of a noncutting stapler (TX60B No-Knife, double-row, 3.5-mm width; Ethicon PROXIMATE) through a 5-cm midline incision that was extended above the observation port.

The animals were fasted overnight before the operation. Ketamine was used to sedate the experimental pigs at a dose of 22 to 30 mg/kg intramuscularly, followed by intravenous administration of 30 mg of propofol (10 mg/mL). After the pigs were anesthetized, a 12-cm upper midline incision was made. The distal stomach was carefully resected, and gastrointestinal tract reconstruction was then performed. For the uncut Roux-en-Y reconstruction, a side-to-side gastrojejunostomy was constructed 30 cm distal to the ligament of Treitz. Occlusion of the jejunal lumen was made 3 cm proximal to the anastomosis by various numbers of staple lines (TX60B No-Knife, double-row, 3.5-mm width; Ethicon PROXIMATE), and Braun's jejunojejunostomy was created 35 cm distal to the anastomosis.
All animals tolerated the procedure. Antibiotics and a liquid diet were administered on postoperative days (PODs) 1 and 2. Next, a normal diet was initiated on POD 3 depending on the general condition of the animals.