Effect of semifundoplication with subtotal gastrectomy for prevention of postoperative gastroesophageal reflux

Acid Secretion and Its Relationship to Esophageal Reflux Symptom in Patients with Subtotal Gastrectomy

BACKGROUND

Esophageal reflux symptom has been reported as common in patients with subtotal gastrectomy. Management of postoperative esophageal reflux symptom is not satisfactory. The aim of this study is to investigate prevalence of esophageal reflux symptom after subtotal gastrectomy and assess factors affecting esophageal reflux symptom in subtotal gastrectomy patients.

METHODS

We prospectively enrolled 100 consecutive patients with subtotal gastrectomy who were regularly followed up by endoscopic examination. Acid secretory capacity was assessed by measuring messenger RNA (mRNA) expression of H⁺/K⁺-adenosine triphosphatase (ATPase) via real-time polymerase chain reaction (PCR) in biopsy specimens.

RESULTS

In total, 47 % of patients had typical esophageal reflux symptom, where heartburn or regurgitation was experienced at least weekly. Age, sex, body mass index, and type of reconstruction did not differ between esophageal reflux and non-esophageal-reflux groups. The esophageal reflux group had longer duration from time of operation until study (median 5.0 versus 3.6 years; P = 0.017). Hill grade for gastroesophageal (GE) flap valve was higher in the esophageal reflux group than in the non-esophageal-reflux group (P = 0.027). H⁺/K⁺-ATPase mRNA expression was higher in the esophageal reflux group than in the non-esophageal-reflux group [3967.6 (± 7583.7) versus 896.2 (± 1456.0); P = 0.006]. Multivariate analysis revealed that postoperative duration, H⁺/K⁺-ATPase mRNA expression level, and GE flap valve disruption were significantly associated with esophageal reflux symptom development.

CONCLUSIONS

Esophageal reflux symptom is common in patients after subtotal gastrectomy, possibly because of anti-reflux-barrier impairment and preservation of acid secretory capacity following surgery. Optimal acid suppression may be helpful in managing postoperative esophageal reflux symptom.

The impact of esophageal reflux-induced symptoms on quality of life after gastrectomy in patients with gastric cancer

Purpose

To evaluate the prevalence of esophageal reflux-induced symptoms after gastrectomy owing to gastric cancer and assess the relationship between esophageal reflux-induced symptoms and quality of life.

Materials and Methods

From January 2012 to May 2012, 332 patients were enrolled in this cross-sectional study. The patients had a history of curative resection for gastric cancer at least 6 months previously without recurrence, other malignancy, or ongoing chemotherapy. Esophageal reflux-induced symptoms were evaluated with the GerdQ questionnaire. The quality of life was evaluated with the European Organization for Research and Treatment QLQ-C30 and STO22 questionnaires.

Results

Of the 332 patients, 275 had undergone subtotal gastrectomy and 57 had undergone total gastrectomy. The number of GerdQ(+) patients was 58 (21.1%) after subtotal gastrectomy, and 7 (12.3%) after total gastrectomy (P=0.127). GerdQ(+) patients showed significantly worse scores compared to those for GerdQ(-) patients in nearly all functional and symptom QLQ-C30 scales, with the difference in the mean score of global health status/quality of life and diarrhea symptoms being higher than in the minimal important difference. Additionally, in the QLQ STO22, GerdQ(+) patients had significantly worse scores in every symptom scale. The GerdQ score was negatively correlated with the global quality of life score (r=-0.170, P=0.002).

Conclusions

Esophageal reflux-induced symptoms may develop at a similar rate or more frequently after subtotal gastrectomy compared to that after total gastrectomy, and decrease quality of life in gastric cancer patients. To improve quality of life after gastrectomy, new strategies are required to prevent or reduce esophageal reflux.

A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: results from a multi-institutional RCT

BACKGROUND

Both Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed as standard procedures, but it has yet to be determined which reconstruction is better for patients. A randomized prospective phase II trial with body weight loss at 1 year after surgery as a primary endpoint was performed to address this issue. The current report delivers data on the quality of life and degree of postoperative dysfunction, which were the secondary endpoints of this study.

METHODS

Gastric cancer patients who underwent distal gastrectomy were intraoperatively randomized to B-I or R-Y. Postsurgical QOL was evaluated using the EORTC QLQ-C30 and DAUGS 20.

RESULTS

Between August 2005 and December 2008, 332 patients were enrolled in a randomized trial comparing B-I versus R-Y. A mail survey questionnaire sent to 327 patients was completed by 268 (86.2%) of them. EORTC QLQ-C30 scores were as follows: global health status was similar in each group (B-I 73.5 ± 18.8, R-Y 73.2 ± 20.2, p = 0.87). Scores of five functional scales were also similar. Only the dyspnea symptom scale showed superior results for R-Y than for B-I (B-I 13.6 ± 17.9, R-Y 8.6 ± 16.3, p = 0.02). With respect to DAUGS 20, the total score did not differ significantly between the R-Y and B-I groups (24.8 vs. 23.6, p = 0.41). Only reflux symptoms were significantly worse for B-I than for R-Y (0.7 ± 0.6 vs. 0.5 ± 0.6, p = 0.01).

CONCLUSIONS

The B-I and R-Y techniques were generally equivalent in terms of postoperative QOL and dysfunction. Both procedures seem acceptable as standard reconstructions after distal gastrectomy with regard to postoperative QOL and dysfunction.

Manometric study of the lower esophageal sphincter and esophagus in subtotal gastrectomy patients

There is controversy in the literature regarding the motor function behavior of the lower esophageal sphincter and esophagus following partial gastrectomy. We studied 26 patients with gastric adenocarcinoma of the distal corpus and/or antrum who underwent radical subtotal gastrectomy with Roux-en-Y reconstruction. There were 15 women (57.69%) and 11 men (42.31%) with a mean age of 57.2 years; 21 were White (80.8%) and five were of African descent (19.2%). Before the surgery and 3 months afterwards, every patient underwent manometric and endoscopic examinations. The lower esophageal sphincter showed reductions in mean respiratory pressure (19.41-15.59 mmHg, P= 0.02) and maximum expiratory pressure (8.13-5.54 mmHg, P= 0.02) without significant alteration in diaphragmatic crura pressure (32.92-30.64 mmHg, P= 0.37). An increase in peristaltic wave amplitude (91.43-124.86 mmHg, P < 0.01) and peristaltic wave conduction velocity (3.29 cm/s to 4.23 cm/s; P= 0.024) were detected in esophageal function. The presence of erosive esophagitis decreased from 10 (38.46%) patients to none (P= 0.002). We concluded that following surgery the lower esophageal sphincter function was impaired, through decreased pressure in the esophageal component without alteration in diaphragmatic crura pressure. On the other hand, there was significant increase in peristaltic wave amplitude and velocity, and improvement of the erosive esophagitis. The authors suggest that subtotal gastrectomy, with gastroesophageal junction preservation, and Roux-en-Y reconstruction should be the preferred operation for distal gastric cancer to minimize esophageal dysfunction and gastroesophageal reflux disease.

Reflux esophagitis in patients with partial gastrectomy and Billroth I or II reconstruction

BACKGROUND

Data on the occurrence of reflux esophagitis and Barrett's esophagus in patients with Billroth I or II resection is sparse. For this reason a cross-sectional study was done in order to assess reflux disease in Billroth resection.

METHODS

Consecutive patients were included in the study. Coincidental pathology (hiatus hernia, ulcer, esophagitis, and cancer) was noted.

RESULTS

Over a period of 12 years, 370 consecutive patients with a partial gastrectomy were seen (268 Billroth II, 102 Billroth I) and three groups of patients were identified. Group 1 included 64 patients (17%) with a hiatus hernia; group 2, 16 patients (4%) with reflux esophagitis; and group 3, 290 patients (78%) with only a Billroth resection. Reflux disease occurred significantly more often in men than in women (7.5% vs. 2%, p<0.05). There was no difference in type of resection or in the presence of reflux esophagitis. Four patients had an esophageal cancer (only one adenocarcinoma).

CONCLUSION

Only a minority of patients with partial gastrectomy has signs of esophagitis in the long term.