Ideal reconstruction after total gastrectomy by the interposition of a jejunal pouch considered by emptying time

A Robotic Completely Intercorporeal Jejunal Pouch Reconstruction after Gastrectomy

Robotic surgery is increasingly gaining importance. While initial results suggest an advantage of the robotic over the minimally invasive approach in patients with gastric cancer, definitive proof of its superiority has yet to be provided. There are numerous approaches to recreate a gastric reservoir after a total gastrectomy. However, a major disadvantage of most conventional reconstructions are long term effects such as dumping syndrome, afferent loop syndrome and poor nutrition intake with severe impact on the patient quality of life. The jejunal pouch reconstruction is a beneficial reconstruction, which provides a larger reservoir capacity after gastrectomy and prevents anastomotic stenosis and dumping syndrome. The completely intercorporeal approach with a Pfannenstiel incision instead of an unfavorable midline incision can potentially decrease delayed complications such as incision hernias. With the increased deployment of robotic surgery, a complete intercorporeal reconstruction is now possible without major increase in operating time or further technical weak points. We provide for the first time a detailed technical explanation of the completely intercorporeal robotic jejunal pouch reconstruction after gastrectomy.

Effects of creating a jejunal pouch on postoperative quality of life after total gastrectomy: A cross-sectional study

AIM

Total gastrectomy results in the complete loss of gastric function and the development of severe postgastrectomy syndrome. During the jejunal pouch procedure following total gastrectomies, a substitute stomach is created to alleviate the effects of postgastrectomy syndrome. However, the procedure's effectiveness remains controversial. This study aimed to explore the effect of jejunal pouch creation after total gastrectomy on postoperative quality of life.

METHODS

A nationwide multi-institutional cross-sectional study, the Postgastrectomy Syndrome Assessment study NEXT, used the Postgastrectomy Syndrome Assessment Scale-45 questionnaire to explore the optimal gastrectomy procedure for cancer located in the upper third of the stomach or around the esophagogastric junction. The questionnaire consists of 45 items consolidated into 19 main outcome measures relating to postgastrectomy symptoms, amount of food ingested, quality of ingestion, ability for working, level of satisfaction for daily life, and the physical and mental component summary of the 8-Item Short Form Health Survey. Eligible completed questionnaires were retrieved from 1909 patients. Of these, the data were analyzed for 1020 patients who underwent total gastrectomy and 93 patients who underwent jejunal pouch creation after total gastrectomy.

RESULTS

Postoperative quality of life was compared between patients with and without pouches. The analysis revealed that patients with pouches, particularly oral pouches, experienced substantially improved postoperative quality of life than those without, even after adjusting for several clinical factors using multiple regression analyses.

CONCLUSION

The results suggest that total gastrectomy with jejunal pouch creation, particularly oral pouches, may significantly improve postoperative quality of life.

Utility of continuous glucose monitoring following gastrectomy

BACKGROUND

Glucose fluctuation after gastrectomy represented by dumping syndrome is a well-known post-gastrectomy syndrome that negatively impacts patient quality of life. However, the current methods of post-gastrectomy glucose monitoring do not comprehensively capture the postoperative blood glucose fluctuations that characterize this.

METHODS

We used a continuous glucose monitoring (CGM) system to document the glycemic profiles of patients undergoing gastrectomy and compared these between patients undergoing distal gastrectomy (DG) and total gastrectomy (TG). To evaluate post-gastrectomy syndromes, including dumping syndrome, we used the Post-gastrectomy Syndrome Assessment Scale 37-item questionnaire. The glycemic profiles were also compared using this tool.

RESULTS

We studied 57 patients who had undergone DG and 13 who had undergone TG between September 2017 and September 2019. Our results revealed larger diurnal glycemic variability and longer periods of nocturnal hypoglycemia after gastrectomy. The dumping score was worse in the TG than in the DG group (TG 2.4 ± 1.4 vs. DG 1.3 ± 1.2, P = 0.0061). Importantly, 30 of 57 DG patients (52.6%) and 5 of 13 TG patients (38.5%) experienced postprandial hypoglycemia following hyperglycemia without hypoglycemic symptoms. There was no correlation between the dumping symptom score and glycemic variability (ρ = 0.0545, P = 0.6662).

CONCLUSIONS

CGM demonstrated diurnal glycemic variability and nocturnal hypoglycemia in patients undergoing gastrectomy. Because some hypoglycemic patients did not develop symptoms and glycemic variability was not necessarily associated with dumping symptom, dumping syndrome must only partially explain the postoperative glucose fluctuations.

A Comparative Study of Double-Tract Reconstruction and Roux-en-Y After Gastrectomy for Gastric Cancer

BACKGROUND

The meta-analysis was performed to compare surgical and functional results of double-tract (DT) and Roux-en-Y (RY) reconstruction, applied in both partial and total gastrectomy.

METHODS

PubMed, Ovid, Web of Science, Wiley, EBSCO, and the Cochrane Library Central were searched for studies comparing DT and RY after partial or total gastrectomy. Surgical, nutritional, and long-term outcomes were collected and analyzed.

RESULTS

A total of 595 patients from 8 studies were included. Operative time, time to first flatus, length of hospital stays, complications, postoperative nutritional variables, and functional result were similar between 2 groups. Group DT had significantly less blood loss, shorter time to oral intake and less loss of body weight at 2 years after operation.

CONCLUSIONS

DT reconstruction is comparable with RY after gastrectomy in safety, surgical outcomes including reflux symptom and postoperative recovery and shows better food intake and body weight maintenance.

Long-term quality of life and nutrition status of the aboral pouch reconstruction after total gastrectomy for gastric cancer: a prospective multicenter observational study (CCOG1505)

BACKGROUND

Several efforts have been made to alleviate harms and symptoms after gastrectomy for gastric cancer. We previously conducted a randomized controlled trial (CCOG1101) to compare quality of life (QOL) and nutritional status between Roux-en-Y (RY) and aboral pouch (AP) reconstructions for up to 1 year after total gastrectomy. However, long-term outcomes after AP reconstruction remain unclear.

METHODS

A prospective multicenter observational study was conducted to compare QOL, body composition, and nutritional indicators between the RY and AP reconstructions at 5 years after surgery among patients who were enrolled in the CCOG1101 trial. QOL was assessed by the PGSAS-37 questionnaires as well as the EORTC QLQ-C30 and STO22.

RESULTS

Sixty patients (31 for RY and 29 for AP) were recruited for analysis. There were no significant differences in baseline and perioperative characteristics between the two groups. No significant differences were found in the EORTC QLQ-C30 global health status and functional scales. Regarding symptom scales in the QLQ-C30 and STO22, a more favorable score for the diarrhea scale was observed in the AP group. Diarrhea was also the only item in the PGSAS-37 questionnaires in which significant benefit of AP was observed. Body weight and lean body mass continued to decrease throughout the postoperative 5 years in both groups. None of the conventional nutritional indicators using the serum samples showed significant difference between the two groups.

CONCLUSIONS

Long-term observation suggested little benefit of AP reconstruction after total gastrectomy other than in alleviating diarrhea.

Nutritional Results of Roux-en-Y Pouch Reconstruction After Total Gastrectomy for Gastric Cancer

Objective:

The aim of the present study was to describe the nutritional advantage of pouch reconstruction.

Summary of background data:

Roux-en-Y (RY) pouch reconstruction might improve patients' quality of life compared with RY reconstruction without a pouch after total gastrectomy for gastric cancer.

Methods:

Clinical records were retrospectively reviewed in 9 and 30 patients with gastric cancer for stages I to III diseases in the pouch and RY groups, respectively, and perioperative and nutritional results were studied. Nutritional results were studied for hemoglobin, serum albumin, total lymphocyte count, and prognostic nutritional index for 5 years postoperatively.

Results:

Intraoperative blood loss did not differ between 2 groups, and operative time in the pouch group was prolonged compared with the RY group. All parameters we studied for nutritional results did not differ between the pouch and RY groups in patients with stages I to III diseases. When nutritional results were investigated in patients with stage I diseases, the total lymphocyte count at 2 years and prognostic nutritional index at 2 and 3 years postoperatively were greater in the pouch group than RY group, but the increase was not obvious at 4 to 5 years after the operation, and serum albumin and hemoglobin did not differ between 2 groups.

Conclusions:

These results indicate that the nutritional advantage of pouch reconstruction is very limited after total gastrectomy because the nutritional benefits of pouch reconstruction were observed in 2 of 4 parameters in patients with stage I at 2 and 3 years postoperatively.

Extreme dilatation of the interposed jejunal pouch after proximal gastrectomy associated with portal venous gas: A case report

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Dilatation of the interposed jejunal pouch developed after proximal gastrectomy.

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Shock state with portal venous gas was restored after conservative therapy.

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The pouch dilatation recurred soon after resuming oral ingestion.

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Resection of the pouch with R-Y esophagojejunostomy relieved the patient.

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Surgical intervention should be considered for refractory pouch dilatation.

Introduction

The jejunal pouch interposition (JPI) after proximal gastrectomy (PG) was proposed as a reconstructive procedure to provide a gastric reservoir substitute and prevent postgastrectomy syndrome. However, food residue remaining in some of the pouches resulted in the adverse effect of abdominal bloating, thereby body weight loss. Here, we report a rare case with an extreme dilation of the interposed jejunal pouch (JP) 8 years after PG, requiring pouch resection.

Presentation of case

A 65-year-old-man who had undergone PG with an inverted U-shaped JPI for early gastric cancer 8 years previously, suffered from shock after right hip joint implantation. Abdominal enhanced CT scan revealed an extremely dilated JP accompanied by portal venous gas. After 5 months of conservative therapy, he underwent resection of the JP and gastric remnant with Roux-en-Y esophagojejunostomy reconstruction. After the operation, the patient has remained in good health for over 3 years.

Discussion and conclusion

Long-term operative outcome following pouch operation for gastric cancer still remains controversial. Surgical intervention should be considered when we encounter patients who have refractory pouch dilatation after surgery for gastric cancer.

A long-term follow-up result of pouch plasty for severe dysfunction of jejunal pouch reconstruction after total gastrectomy: a case report

A 78-year-old woman with malignant lymphoma of the stomach underwent total gastrectomy with a jejunal-pouch (J-pouch) reconstruction in 1994. Twelve years after surgery the patient began to suffer epigastric distress and reflux symptoms. Eventually, she was unable to take anything by mouth. A series of diagnostic images seemed to indicate that the main cause of the dysfunction was flaccidity of the J-pouch and deformity of the outflow route induced by chronic excessive dilatation of the pouch wall. Because all conservative managements only led to temporary improvement and ended in failure, she hoped to receive the operation. We designed "pouch plasty" capable of ameliorating the pouch dysfunction. The aim of pouch plasty was to improve uneven tension of the pouch wall and repair deformity of the outflow route of the food. After the operation, the J-pouch resumed adequate drainage and had good reservoir function. More than 7 years later, the patient had no further complications.

Reconstruction with Jejunal Pouch after Gastrectomy for Gastric Cancer

The construction of a gastric substitute pouch after gastrectomy for gastric cancer has been proposed to help ameliorate postprandial symptoms and nutritional performance. Adequate reconstruction after gastrectomy is an important issue, because postoperative patient quality of life (QOL) primarily depends on the reconstruction method. To this end, jejunal pouch (JP) reconstructions were developed to improve the patient's eating capacity and QOL by creating large reservoirs with improved reflux barriers to prevent esophagitis and residual gastritis. It is important that such reconstructions also preserve blood and extrinsic neural integrity for maintaining pouch function, because JP motility is associated directly with QOL. Some problems remain to be resolved with the JP reconstructions method including gastrointestinal motility, which plays a major role in food transfer, digestion, and absorption of nutrients. Further studies including basic research and larger prospective randomized control trials are also needed to obtain definitive results. With persistent innovations in surgical techniques, JP after gastrectomy could become a safe and preferable reconstructive modality to improve patient QOL after gastrectomy.

Pouch size influences clinical outcome of pouch construction after total gastrectomy: A meta-analysis

AIM: To assess the clinical significance of pouch size in total gastrectomy for gastric malignancies.

METHODS: We manually searched the English-language literature in PubMed, Cochrane Library, Web of Science and BIOSIS Previews up to October 31, 2013. Only randomized control trials comparing small pouch with large pouch in gastric reconstruction after total gastrectomy were eligible for inclusion. Two reviewers independently carried out the literature search, study selection, data extraction and quality assessment of included publications. Standard mean difference (SMD) or relative risk (RR) and corresponding 95%CI were calculated as summary measures of effects.

RESULTS: Five RCTs published between 1996 and 2011 comparing small pouch formation with large pouch formation after total gastrectomy were included. Eating capacity per meal in patients with a small pouch was significantly higher than that in patients with a large pouch (SMD = 0.85, 95%CI: 0.25-1.44, I² = 0, P = 0.792), and the operative time spent in the small pouch group was significantly longer than that in the large pouch group [SMD = -3.87, 95%CI: -7.68-(-0.09), I² = 95.6%, P = 0]. There were no significant differences in body weight at 3 mo (SMD = 1.45, 95%CI: -4.24-7.15, I² = 97.7%, P = 0) or 12 mo (SMD = -1.34, 95%CI: -3.67-0.99, I² = 94.2%, P = 0) after gastrectomy, and no significant improvement of post-gastrectomy symptoms (heartburn, RR = 0.39, 95%CI: 0.12-1.29, I² = 0, P = 0.386; dysphagia, RR = 0.86, 95%CI: 0.58-1.27, I² = 0, P = 0.435; and vomiting, RR = 0.5, 95%CI: 0.15-1.62, I² = 0, P = 0.981) between the two groups.

CONCLUSION: Small pouch can significantly improve the eating capacity per meal after surgery, and may improve the post-gastrectomy symptoms, including heartburn, dysphagia and vomiting.

Tissue engineering of the stomach

Tissue engineering combines engineering principles with the biological sciences to create functional replacement tissues. The underlying principle of tissue engineering is that isolated cells combined with biomaterials can form new tissues and organs in vitro and in vivo. This review focuses on stomach tissue engineering, which is a promising approach to the treatment of gastric cancer, the fourth most common malignancy in the world and the second-leading cause of cancer mortality worldwide. Although gastrectomy is a reliable intervention to achieve complete removal of cancer lesions, the limited capacity for food intake after resection results in lower quality of life for patients. To address this issue, we have developed a tissue-engineered stomach to increase the capacity for food intake by creating a new food reservoir. We have transplanted this neo-stomach as a substitute for the original native stomach in a rat model and confirmed functional adaptation. Furthermore, we have demonstrated the feasibility of transplanting a tissue-engineered gastric wall patch in a rat model to alleviate the complications after resection of a large area of the gastric wall. Although progress has been achieved, significant challenges remain to bring this approach to clinical practice. Here, we summarize our work and present the state of the art in stomach tissue engineering.

Comparative evaluation of two reconstructive methods following laparoscopic assisted subtotal gastrectomy in dogs

BACKGROUND

Laparoscopic gastrectomy is a new and technically challenging surgical procedure with potential benefit. The objective of this study was to investigate clinical and para-clinical consequences following Roux-en-Y and Jejunal Loop interposition reconstructive techniques for subtotal gastrectomy using laparoscopic assisted surgery.

RESULTS

Following resection of the stomach attachments through a laparoscopic approach, stomach was removed and reconstruction was performed with either standard Roux-en-Y (n = 5) or Jejunal Loop interposition (n = 5) methods. Weight changes were monitored on a daily basis and blood samples were collected on Days 0, 7 and 21 post surgery. A fecal sample was collected on Day 28 after surgery to evaluate fat content. One month post surgery, positive contrast radiography was conducted at 5, 10, 20, 40, 60 and 90 minutes after oral administration of barium sulfate, to evaluate the postoperative complications. There was a gradual decline in body weight in both experimental groups after surgery (P < 0.05). There was no difference in blood parameters at any time after surgery between the two methods (P > 0.05). Fecal fat content increased in the Roux-en-Y compared to the Jejunal loop interposition technique (P < 0.05). No major complications were found in radiographs and gastric emptying time was similar between the two groups (P > 0.05).

CONCLUSION

Roux-en-Y and Jejunal loop interposition techniques might be considered as suitable approaches for reconstructing gastro-intestinal tract following gastrectomy in dogs. The results of this study warrant further investigation with a larger number of animals.

Questionnaire survey regarding the current status and controversial issues concerning reconstruction after gastrectomy in Japan

The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy conducted a nationwide questionnaire survey to clarify the current status of reconstruction after gastrectomy. One hundred and forty-five institutions (66%) responded to the survey. The questionnaire dealt with the reconstruction after a distal gastrectomy, pylorus-preserving gastrectomy (PPG), total gastrectomy, and proximal gastrectomy. The most common method of reconstruction after distal gastrectomy was Billroth I in 112 institutions (74%), and Roux-en-Y (RY) in 30 (21%). Seventy-seven institutions (53%) responded to the PPG questions. The lengths of the antral cuff were widely distributed among the institutions. Segmental gastrectomy was performed by 23 institutions for limited cases. The most common method of reconstruction after total gastrectomy was RY in 138 institutions (95%). Reconstruction with a pouch after total gastrectomy was done in 26 institutions (18%). The most common reconstructions after proximal gastrectomy were esophagogastrostomy in 69 institutions (48%), jejunal interposition in 41 (28%), double tract in 19 (13%) and pouch reconstruction in 6 (7%). Although most Japanese surgeons are concerned about the revised methods of reconstruction and quality of life after gastrectomy, surgeons have not yet reached a full consensus on these issues.

Optimal size of jejunal pouch as a reservoir after total gastrectomy: a single-center prospective randomized study

BACKGROUND

In order to improve a patient's quality of life after total gastrectomy, jejunal pouch reconstruction has been employed. However, little information exists regarding the optimal size of the jejunal pouch after total gastrectomy.

METHODS

The study was designed as a single-center randomized trial in which the results of double-tract reconstruction with pouches of two different sizes were compared, i.e., short and long pouch double tract (SPDT and LPDT, respectively). We conducted a clinical assessment with standard questionnaire after surgery. The amount of residual food in the jejunal pouch was determined by endoscopy.

RESULTS

No demographic differences were noted between the two groups. The eating capacity per meal was higher in the SPDT group than in the LPDT group. The postoperative weight loss 24 months after surgery was lower in SPDT group than that in the LPDT group. Although the incidence of early dumping symptoms was higher in the SPDT group, no difference was noted in the other postprandial abdominal symptoms between the two groups.

CONCLUSIONS

We conclude that the optimal pouch should be relatively short, as a short pouch improves the eating capacity per meal and the weight loss ratio to the preoperative value.

Distal pouch reconstruction with transverse jejunoplasty after experimental gastrectomy

PURPOSE

Various reconstruction methods with or without reservoir formation after total gastrectomy have been established. Transverse intestinoplasty has benefits as a functional peristalsis modification in rectal resections. In this study, we evaluate a distal pouch combined with a transverse jejunoplasty compared to standard Roux-en-Y reconstruction.

METHODS

Total gastrectomy was performed on 23 pigs randomly assigned to 3 reconstruction groups-group 1 (n = 7): esophagojejunostomy without a pouch, group 2 (n = 8): esophagojejunostomy with a distal pouch, and group 3 (n = 8): distal pouch with a transverse jejunoplasty. Seven days postoperatively, weight was measured, and X-ray examinations were conducted for 1 h after oral contrast medium application. Blood glucose levels after oral glucose intake and the volume of the pouch loop were evaluated.

RESULTS

Upper jejunal passage was delayed and the mean volume of the jejunal loop increased by pouch formation compared to controls (p < 0.05). Body weight was the best for the pouch group with jejunoplasty (-1.9 ± 0.8% vs. pouch alone -3.3 ± 2.4% vs. no pouch -7.5 ± 2.1%, p < 0.05).

CONCLUSIONS

The distal jejunal pouch after total gastrectomy offers advantages with respect to bowel passage and postoperative nutrition status compared to standard Roux-en-Y reconstruction. The combination of a distal pouch and transverse jejunoplasty may provide additional functional benefits.

A new pouch reconstruction method after total gastrectomy (pouch-double tract method) improved the postoperative quality of life of patients with gastric cancer

PURPOSE

Many reconstruction methods after total gastrectomy (TG) lead patients to dumping syndrome, reflux esophagitis, and poor postoperative quality of life (QOL). To improve patients' postoperative QOL after TG, we introduce a new reconstruction method named "pouch-double tract" (PDT).

METHODS

A prospective randomized study was performed between 2005 and 2007 in 29 patients who were diagnosed as stage I or II gastric cancers preoperatively. Patients were followed until the end of 2009. Conventional Roux-en-Y reconstruction (RY) was performed in 15 patients, and PDT was used in 14 patients. Postoperative patients' nutritional assessments and patients' QOL were compared between the groups.

RESULTS

PDT did not increase morbidity or mortality compared with RY. Patients in the PDT group did not complain of dumping and showed better postoperative food intake. Body weight recovered better in PDT than in RY.

CONCLUSION

PDT is safe and associated with better nutritional status compared with the RY.

Early dumping syndrome and reflux esophagitis prevention with pouch reconstruction

BACKGROUND

Total gastrectomy causes numerous disorders, such as reflux esophagitis, dumping syndrome, malabsorption, and malnutrition. To minimize the consequences, different variants of reconstruction are performed. The aim of our study is the comparison of two reconstructive methods: the standard Roux-en-Y and a new modality of pouch interposition, preduodenal-pouch interposition. This study aims to investigate the advantage of bile reflux prevention and to reduce symptoms of dumping syndrome after 3- and 6-mo follow-up.

MATERIALS AND METHODS

A total of 60 patients were divided in two groups: (A) 30 patients with Roux-en-Y reconstruction, and (B) 30 patients with the preduodenal-pouch (PDP) type of reconstruction. Endoscopic examination and endoluminal jejunal limb pressure measurements were performed. Scintigraphic measurements of half-emptying time were performed to evaluate meal elimination in the context of reflux esophagitis and early dumping syndrome. The Japan Society of Gastrointestinal Surgery has provided guidelines with which to classify the symptoms of early dumping syndrome. Patients were followed up for periods of 3 and 6 mo after the surgery.

RESULTS

Our study groups did not differ with regard to the level of reflux esophagitis (P = 0.688). Average values of pressure at 10 and 15 cm below the esophago-jejunal junction were significantly lower in the PDP group (P < 0.001). Elimination of the test meal between two groups was not significant (P = 0.222). Evaluation of early dumping syndrome symptoms revealed a significant reduction among PDP patients after 3 and 6 mo.

CONCLUSION

Our study showed significant superiority of the new pouch reconstruction over the standard Roux-en-Y approach in the treatment of early dumping syndrome.

Improved long-term quality of life in patients with laparoscopy-assisted distal gastrectomy with jejunal pouch interposition for early gastric cancer

BACKGROUND

Although laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) offers more advantages than open distal gastrectomy, it does not eliminate the postgastrectomy syndrome, which can negatively impact quality of life (QoL). In this paper, we investigate jejunal pouch interposition (JPI) during LADG and evaluate its potential for long-term use.

MATERIALS AND METHODS

Between April, 2004 and April, 2005, 28 patients underwent LADG with JPI (LA-JPI), and an equal number underwent LADG with Billroth-II gastrojejunostomy (LA-B-II). Of these, 25 patients with LA-JPI and 28 with LA-B-II, surviving more than 4 years, were enrolled. We compared clinicopathological characteristics, surgical outcomes, and the patients' QoL.

RESULTS

There were no differences in clinicopathological characteristics and surgical outcomes except longer operation time of LA-JPI group than LA-B-II group (P < 0.001). The gastrofiberscopy, performed 4 years after surgery, demonstrated significant higher incidence of bile reflux gastritis in LA-B-II group(P = 0.03). In terms of QoL metrics, we identified a significantly lower incidence rate of appetite change, heartburn, and reductions in physical strength and daily activity levels in the LA-JPI group. In addition, satisfaction with the operative procedure and postoperative life were higher. Although the number of meals per day did not differ, we noted a significantly greater food intake with each meal compared with the preoperative metric (P = 0.04) and reduced body weight loss (P = 0.003) was observed in the LA-JPI group.

CONCLUSIONS

These long-term follow-up results suggest that LA-JPI might alleviate postgastrectomy syndrome and that this could help improve the QoL in patients with EGC.

Clinical results of various reconstructions employed after total gastrectomy

Methods of restoring continuity after total gastrectomy, particularly those creating a "reservoir," have led to many publications over the last 20 years. These publications are herein reviewed in an attempt to answer questions regarding the clinical value of a jejunal "reservoir". The conclusion we reached from this review was that such a reconstruction does reduce unpleasant symptoms, aids weight maintenance, and is a valuable operative approach.

New Type of Jejunal Interposition Method after Gastrectomy

BACKGROUND

Total and subtotal gastrectomies are methods of choice in surgical treatment of gastric cancer. These ablative operations eliminate the gastric reservoir and severely alter digestive physiology.

METHODS

We have created a unique method of reconstruction of "the jejunal pouch" following gastrectomy using the first loop of the jejunum together with the formation of antireflux anastomosis.

RESULTS

An analysis of the results of the application of a new way of reconstruction of the digestive path was carried out. Seventy-five patients with gastric cancer received the new type of reconstruction. Among them, there were 52 men and 23 women aged 36-72 years. In the new interposition method group, in the first year after the surgical operation, the patients returned to 89.8% of their original body weight and in the second year to 89.7%; and in the Roux-en-Y group the patients returned to 64.4% and 59.2% of their body weight respectively. Further body weight fluctuations in patients after the new operative technique were determined by diet and aging and were not connected with digestive disorders. In the group receiving the new operative technique, the dumping syndrome was recorded in 4 (5.3%) patients and in the Roux-en-Y operation this syndrome occurred in 22 (27.5%) patients more than 1 year following the operations. There were no cases of reflux disease in the group undergoing the new operative technique. The average evacuation time of the "jejunal pouch" was 84+/-9.8 min after the new operation and 57.5+/-10.1 minutes after the Roux-en-Y operation.

CONCLUSIONS

The comparative analysis of the results of the new operation (75 patients) with 80 patients (who were operated on using the traditional method) after the Roux-en-Y operation showed the significant advantages of the new method due to a diminished occurrence of troublesome gastrointestinal symptoms. We consider that the reconstruction of the gastrointestinal tract after total gastrectomy should give the maximal comfort for the rest of the patient's life.

Laparoscopically assisted total gastrectomy with jejunal pouch interposition

BACKGROUND

Jejunal pouch interposition (JPI) is known as a useful gastric replacement procedure after total gastrectomy. The JPI procedure, however, has not been applicable to laparoscopically assisted total gastrectomy (LATG) because of its technical complexity and difficulty. This study aimed to describe our modified LATG/JPI technique, and to evaluate its feasibility, safety, and early postoperative functional outcome.

METHODS

Between September 2002 and August 2003, LATG/JPI was attempted for five patients (3 men and 2 women) with early gastric cancers in the upper portion of the stomach. The mean age of the patients was 57 years, and their BMI was 21 kg/m2. Using a 5-port technique, the gastric arteries were laparoscopically clipped and divided with adequate lymphatic dissection. After completion of gastric resection, the anvil of a circular stapling device was placed in the esophageal stump. An 8-cm minilaparotomy then was performed, and the 12-cm pouch was created extracorporeally in the "reverse U" fashion. The stapled pouch-esophagostomy was performed under laparoscopic monitoring. The remainder of the procedure was accomplished under direct vision.

RESULTS

All cases were managed laparoscopically without any complications. The mean operating time was 407 min, and the blood loss was 279 ml. All the patients showed rapid and uneventful recovery. Postoperative studies, including dual scintigraphy, showed that all jejunal pouches were satisfactorily functioning.

CONCLUSIONS

This study showed LATG/JPI to be feasible and safe. With technical modifications, LATG/JPI can become a potentially effective option for improving patients' quality of life after total gastrectomy.