Medium- and Long-Term Results of Jejunal Pouch Reconstruction After a Total and Proximal Gastrectomy

An improvement in the reconstruction of digestive tract after total gastrectomy: ultra-short cecum

Aim

This study aimed to evaluate the utility and complications of ultra-short cecum (USC) in the reconstruction of digestive tract after total gastrectomy (TG) for the alleviation of reflux esophagitis and to determine its effect on long-term nutritional status.

Methods

Patients who underwent TG with USC or normal cecum (NC) at a single institution between June 2018 and December 2020 were included in this study. The inclusion and exclusion criteria were defined, and the primary endpoints were reflux esophagitis, anastomotic leakage and postoperative nutritional status. The long-term nutritional status was evaluated by the change trend of laboratory blood tests, including total protein, prealbumin, hemoglobin, and total leukocytes.

Results

Totally 240 cases were included in the final analysis out of 496 patients who received TG with USC or NC. Postoperative reflux esophagitis was significantly higher in the NC group than in the USC group (24.7% versus 7.7%, P = 0.001), and the NC group had a higher incidence of severe esophagitis symptoms compared to the USC group (13.6% versus 0.00%, P < 0.001), and the incidence of anastomotic leakage in the USC group was similar to that in the NC group (9.0% versus 6.2%, P = 0.6). There was no significant difference in long-term nutritional status between the USC and NC groups in the two years following the surgery (P > 0.05).

Conclusion

Ultra-short cecum after total gastrectomy should be more actively recommended due to its significant reduction in reflux esophagitis and similar incidence of anastomotic leakage and nutritional status compared with normal cecum after total gastrectomy.

Current status of laparoscopic proximal gastrectomy in proximal gastric cancer: Technical details and oncologic outcomes

The incidence of proximal gastric cancer has been increasing continuously. This status has prevailed despite the application of laparoscopic proximal gastrectomy as a surgical treatment for early proximal gastric cancer. The widespread adoption and standardization of this surgical procedure as the primary treatment for the abovementioned cancer has been hampered by the lack of consensus on the optimal reconstruction method after proximal gastrectomy. In addition, the oncological safety of proximal gastrectomy for advanced gastric disease remains unclear. We reviewed the English-language literature to clarify the current status of laparoscopic proximal gastrectomy in proximal gastric cancer. Japanese gastric cancer guidelines have suggested three types of reconstructions for proximal gastrectomy, namely, esophagogastrostomy, double-tract reconstruction, and jejunal interposition. Optimal reconstruction methods remain to be determined because of the lack of adequately performed and well-designed randomized controlled trials. The technical complexity and challenging implementation of reconstruction procedures have resulted in several complications with anastomoses. Multicenter randomized controlled trials are necessary to evaluate the various reconstruction methods and the oncological safety of laparoscopic proximal gastrectomy for advanced gastric disease.

Reconstruction methods after radical proximal gastrectomy: A systematic review

BACKGROUND

The incidence of tumors located in the upper third of the stomach is increasing, and the use of radical proximal gastrectomy is becoming prevalent. After a proximal gastrectomy, various reconstructions are performed, but surgical outcomes are controversial. This study was performed to review clinical outcomes of reconstructions after proximal gastrectomy.

METHODS

Inclusion criteria focused on postoperative complications of patients who underwent a proximal gastrectomy for gastric cancer. Exclusion criteria were case reports; targeted data not investigated; a duplicate study reported in a larger cohort; esophageal sphincter preservation surgery; near-total gastrectomy; recurrence of tumor; and combined organ resection.

RESULTS

In total, 22 retrospective and 2 prospective studies were included. The studies investigated surgical outcomes of esophagogastrostomy (n = 10), jejunal interposition (n = 12), jejunal pouch interposition (n = 7), double tract jejunal interposition (n = 1), and tube-like stomach esophagogastrostomy (n = 5). Pooled incidences of reflux esophagitis or reflux symptoms for these procedures were 28.6%, 4.5%, 12.9%, 4.7%, and 10.7%, respectively. Incidences of postoperative complications were 9.5%, 18.1%, 7.0%, 11.6%, and 9.3%, respectively.

CONCLUSIONS

Despite increasing operation complexity, which perhaps increased the risk of other postoperative complications, currently used reconstructions present excellent anti-reflux efficacy. However, the optimal reconstruction method remains to be determined.

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.

A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy

BACKGROUND

An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem.

METHODS

We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005.

RESULTS

Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group.

CONCLUSIONS

The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.

Clinical outcome of lower esophageal sphincter- and vagus-nerve-preserving partial cardiectomy for early gastric cancer of the subcardia

BACKGROUND

No definitive operative method has been established for the treatment of early subcardial gastric cancer. Our newly developed technique involves local resection of the subcardia while preserving the lower esophageal sphincter and vagus nerve. A new fornix is constructed to accept the transposed esophagus.

METHODS

Thirty patients underwent this procedure between July 2003 and December 2010. Continuous gastric pH monitoring was performed immediately after surgery, and esophageal manometry was undertaken 1 month later. Serum total protein, albumin, total cholesterol, cholinesterase, and body mass index (BMI) were recorded every 3 months. Pre- and postoperative oral intake were compared, reflux symptoms were recorded, and reflux esophagitis was assessed by endoscopy after 1 year.

RESULTS

Twenty-five patients (86 %) reported no symptoms of reflux, and 27 (92.8 %) patients could eat 70 % or more of what they had eaten before surgery. Lower esophageal pressures were found to be >10 mmHg in 66.7 % of patients, and the fraction of time that pH <4 was <5 % of the 24-h monitoring period in 70 %. Serum parameters and BMI were unchanged.

CONCLUSIONS

This surgical technique is a useful means of preserving postoperative quality of life after local gastrectomy by preventing reflux and maintaining nutritional status.

HER2/neu over-expression predicts poor outcome in early gastric cancer without lymph node metastasis

PURPOSE

Human epidermal growth factor receptor 2 (HER2/neu) is involved in the pathogenesis of several types of cancer, including gastric cancer. However, there remains a paucity of data regarding the prognostic relevance of HER2/neu in early gastric cancer without lymph node metastasis (pN0 EGC). The aim of our study was to analyze whether the over-expression of HER2/neu significantly predicts poor outcomes of pN0 EGC.

PATIENTS AND METHODS

Sixty-seven patients who underwent operative resection for pN0 EGC was enrolled. The HER2/neu status was examined by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH).

RESULTS

The HER2/neu-positive rate was 16.4%. HER2/neu over-expression showed a significant correlation with histological type (P ≤ 0.001), tumor location (P=0.022) and Lauren grade (P=0.012). Multivariate analysis showed HER2/neu serves as a good prognostic marker to predict the risk of poor outcome for pN0 EGC. (HR=1.384, 95.0% CI: 1.142-1.897 P=0.005) CONCLUSION: Considering HER2/neu over-expression significantly predicts poor outcome in pN0 EGC, accurate HER2/neu assessment would be done before endoscopic therapy. For HER2/neu-positive patients, radical surgery should be performed.

Comparison of perioperative and long-term outcomes of total and proximal gastrectomy for early gastric cancer: a multi-institutional retrospective study

BACKGROUND

Various surgical procedures are used to treat early gastric cancers in the upper third of the stomach (U-EGCs). However, there is no general agreement regarding the optimal surgical procedure.

METHODS

The medical records of 203 patients with U-EGC were collected from 13 institutions. Surgical procedures were classified as Roux-en-Y esophagojejunostomy after total gastrectomy (TG-RY), esophagogastrostomy after proximal gastrectomy (PG-EG), or jejunal interposition after PG (PG-JI). Patient clinical characteristics and perioperative and long-term outcomes were compared among these three groups.

RESULTS

TG-RY, PG-EG, and PG-JI were performed in 122, 49, and 32 patients, respectively. Tumors were larger in TG-RY patients than in PG-EG and PG-JI patients, and undifferentiated-type gastric adenocarcinoma tended to be more frequent in TG-RY than in PG-EG. The operative time was shorter for PG-EG than for PG-JI and TG-RY. Hospital stay and early postoperative complications were not different for the three procedures. With respect to gastrectomy-associated symptoms, a "stuck feeling" and heartburn tended to be more frequent in PG-EG patients, while dumping syndrome and diarrhea were more frequent in TG-RY patients. Post-surgical weight loss was not different among the three groups, however, serum albumin and hemoglobin levels tended to be lower in TG-RY patients.

CONCLUSION

Three surgical procedures for U-EGC did not result in differences in weight loss, but PG-EG and PG-JI were better than TG-RY according to some nutritional markers. In U-EGC, where patients are expected to have long survival times, PG-EG and PG-JI should be used rather than TG-RY.

Impact of jejunal pouch interposition reconstruction after proximal gastrectomy for early gastric cancer on quality of life: short- and long-term consequences

BACKGROUND

Proximal gastrectomy with jejunal pouch interposition (JPI) reconstruction has been advocated as a function-preserving surgery in patients with early gastric cancer located in the upper third of the stomach.

METHODS

This study clinically investigated 22 patients who underwent JPI reconstruction and 22 patients who underwent Roux-en-Y (RY) reconstruction after total gastrectomy for stage IA/IB gastric cancer. Patients in the 2 groups were compared to evaluate the short- and long-term postoperative outcomes.

RESULTS

Morbidity and nutritional parameters were no different between the 2 groups. Although postoperative food intake volume was significantly superior in JPI patients than in RY patients 1 year postsurgery, the change in body weight was equal. JPI patients outperformed RY patients with a better quality of life (QOL) at 1 year postgastrectomy. However, 5 years after the surgery, both groups had a similar QOL except for fatigue.

CONCLUSIONS

JPI reconstruction leads to better outcomes including QOL than RY reconstruction in the short term. However, this short-term positive impact of JPI decreases over time.

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.

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.

Extent of gastric resection impacts patient quality of life: the Dysfunction After Upper Gastrointestinal Surgery for Cancer (DAUGS32) scoring system

BACKGROUND

Quality of life is an important outcome measure in the care of patients with cancer. We developed a new scoring system specifically for the evaluation of patients with upper gastrointestinal cancer and postoperative gastrointestinal dysfunction. This study was undertaken to evaluate the scoring system's validity in comparing outcomes after gastric resection.

MATERIALS AND METHODS

Patients with gastric cancer, 3 months to 3 years postoperatively, were surveyed using the survey instrument. Postoperative dysfunction scores and the status of resuming activities of daily living were compared with the surgical procedure performed by analysis of variance and multiple-comparison techniques.

RESULTS

Of 211 patients surveyed, 165 (119 men, 46 women; mean age, 65.1 ± 10.5 years) responded. Procedures included distal gastrectomy in 100, total gastrectomy in 57, and pylorus-preserving gastrectomy in 8. The overall dysfunction score was 61.8 ± 15.5. The dysfunction score was 58.9 ± 15.0 after distal gastrectomy, 66.8 ± 14.1 after total gastrectomy, and 62.4 ± 21.6 after pylorus-preserving gastrectomy. These values differed significantly among the groups (P = .007). Dysfunction scores according to postoperative activity status were 49.1 ± 15.6 in 71 patients who resumed their activities, 56.9 ± 15.7 in 39 patients with reduced activities, 57.3 ± 8.8 in 15 patients with minimal activities, and 63.3 ± 11.8 (P < .05) in 16 patients who did not resume activities because of poor physical condition.

CONCLUSIONS

This scoring system for postoperative gastrointestinal dysfunction provides an objective measure of dysfunction related to specific surgical procedures and correlates with activities of daily living in the postoperative period.

Uncut Roux-en-y esophagojejunostomy: A new reconstruction technique after total gastrectomy

PURPOSE

Uncut Roux-en-y is a reconstruction method with a main purpose of diminishing Roux stasis syndrome. In this study we performed this procedure to evaluate utility and complications of this technique, as well as its effect on Roux stasis syndrome.

METHODS

Total gastrectomy with Uncut Roux-en-y esophagojejunostomy was performed on 94 patients. This technique consists of an artificial jejunal occlusion 5 cm proximal to anastomosis and a jejunojejunostomy between afferent and efferent loops. Diagnosis of "Roux stasis syndrome" was made by clinical criteria.

RESULTS

According to the mentioned criteria, the "Roux stasis syndrome" occurred in 21.2% of the patients. Whereas occurrence rate of other complications was: dysphasia (13.8%), benign stricture in anastomosis (9.6%), and fistula (5.3%).

CONCLUSIONS

Comparing the results of our study to other related studies indicates that this type of operation has lower rate of "Roux stasis syndrome", and also decreases the postoperative stricture rate of the anastomosis.

The possibility of performing a limited resection and a lymphadenectomy for proximal gastric carcinoma based on sentinel node navigation

PURPOSE

This study examined the possibility of performing a limited resection and a lymphadenectomy with sentinel node navigation surgery (SNNS) for the treatment of proximal gastric carcinoma.

METHODS

Thirty patients with cT1N0 (n = 23) and cT2N0 (n = 7) proximal gastric carcinoma that was located primarily in the U area (the upper third of the stomach) were enrolled. indocyanine green (ICG; 0.5 ml) was injected endoscopically into the submucosa of the four quadrants encompassing the cancer. Twenty minutes after injection, infrared ray electronic endoscopy (IREE) was used to identify the lymph nodes that were stained with ICG (sentinel nodes, SNs) around the serosa and surrounding fat tissue.

RESULTS

One hundred percent of the SNs were identified with our SNNS method. The most common location of SNs was No. 3 (T1: 78%, T2: 100%). The main route of lymphatic drainage was from No. 1 or No. 3 to No. 7 (T1: 95%, T2: 100%). In T1 cancer, Indocyanine green was not distributed to the right gastric area, and no patients had SNs in No. 5 or No. 8a. Four cT2 cancer patients had lymph node metastases, all of which were SNs. There were no cases of postoperative metastasis or recurrence.

CONCLUSIONS

For the cT1 proximal gastric carcinoma patients, limited dissection of the ICG tracer-positive lymphatic areas alone by SNNS using IREE may be acceptable. The main lymphatic drainage route of proximal gastric carcinoma is the left gastric artery area (Nos. 1, 3, and No. 7) and dissection of this area is important.