Reconstruction after proximal gastrectomy using a stapled, U-shaped jejunal pouch

Reconstruction after proximal gastrectomy for early gastric cancer in the upper third of the stomach: an analysis of our 13-year experience

BACKGROUND

Fundoplication during esophagogastrostomy (EG) after proximal gastrectomy (PG) is a useful procedure to prevent reflux esophagitis, but it is unclear how much of the remnant stomach should be wrapped around the esophagus.

METHODS

We analyzed data from 101 patients who underwent PG for upper third early gastric cancer between 1999 and 2011. In all, 64 patients underwent EG, 25 underwent jejunal interposition (JI), and 12 underwent jejunal pouch interposition (JPI). We compared intraoperative details and postoperative outcomes, and investigated the relationships between the degree of the fundoplication during EG and endoscopic findings.

RESULTS

The length of the operation was significantly shorter in the EG group than in the other 2 groups (P < .05), and the intraoperative blood loss was significantly less in the EG group (P < .05). The JI and the JPI groups had significantly greater rates of early complications than did the EG group (P = .01). Reflux esophagitis was present in 22% of patients in the EG group, 8% in the JPI group, and none in the JI group. In the EG group, reflux esophagitis was significantly less common in patients with a >180° wrap of the remnant stomach around the esophagus than in patients with a smaller wrap (P = .0008). The rate of body weight loss was significantly less in the EG group compared with the other 2 groups (P < .05).

CONCLUSION

Considering the low invasiveness of the procedure and postoperative outcomes, we consider that EG with a >180° wrap as the optimal reconstructive procedure.

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.

Laparoscopy-assisted proximal gastrectomy with sentinel node mapping for early gastric cancer

BACKGROUND

Laparoscopy-assisted proximal gastrectomy (LAPG) remains a relatively uncommon procedure because of certain technical issues, such as curability, safety, and retention of postoperative patients' quality of life. The aim of the present study was to evaluate the feasibility of a newly developed LAPG procedure for early-stage proximal gastric cancer.

METHODS

We enrolled 37 consecutive patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the upper third of the stomach with the primary tumor diameter less than 4 cm. Laparoscopy-assisted proximal gastrectomy with sentinel node (SN) mapping and esophagogastric anastomosis with a circular stapler and transoral placement of the anvil was attempted.

RESULTS

The LAPG procedure was completed in 36 patients. It was converted to laparoscopy-assisted total gastrectomy in one patient because one SN detected intraoperatively was positive for metastasis by intraoperative pathological diagnosis. There were no severe postoperative complications in any patient. Only one patient (3%) complained of mild reflux symptoms immediately after operation, which were graded endoscopically as B by the Los Angeles Classification of gastroesophageal reflux disease; however, the symptoms were controlled well by a proton-pump inhibitor. Sentinel nodes were detected successfully in 37 (100%) of our patients. The mean number of dissected lymph nodes and identified SNs per case was 29.7 and 5.8, respectively. The sensitivity of prediction of nodal metastasis (including isolated tumor cells) and diagnostic accuracy based on SN status were 100% (3/3) and 100% (37/37), respectively. All patients have been free from recurrence for a median follow-up period of 26 months.

CONCLUSIONS

This study reveals that our novel LAPG approach is curative and represents a feasible minimally invasive surgical procedure with minimal morbidity and postoperative reflux esophagitis in patients with upper-third early-stage gastric cancer.

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

To establish the ideal form of the pouch for jejunal pouch interposition reconstruction (JPI) after total gastrectomy, the postoperative gastrointestinal function and symptoms were investigated in comparison with jejunal interposition reconstruction (JI). A total of 20 patients who underwent curative surgery for gastric cancer were enrolled in this study. In the JI group (n = 9), an isoperistaltic jejunum about 40 cm in length was interposed between the esophagus and the duodenum. In the JPI group n = 11), a proximal pouch about 15 cm in length with a 10-cm conduit was also interposed between the esophagus and the duodenum. At follow-up 6 months postoperatively, food transit was evaluated using a radiolabeled semisolid test meal. The half-emptying time was 6.9 minutes in the JI group and 46 minutes in the JPI group. The reservoir function influenced the recovery of the patients' body weight and development of the serum total protein in the early postoperative period. An early half-emptying time caused dumping symptoms in JI group. In the JPI group, there were no dumping symptoms; however, extended food clearance of pouch causes postprandial symptoms such as reflux (1 patient), vomiting (2 patients), and discomfort (2 patients). In those patients with symptoms, half-emptying times were longer than 60 minutes. There was a statistically significant correlation between the pouch length and the half-emptying time of the gastric substitute in JPI group (p = 0.0039, r = 0.789). If we estimate that the appropriate half-emptying time is 20 to 60 minutes, correlation of the pouch length and the half-emptying time shows that the ideal pouch length is about 12-15 cm in JPI. In jejunal pouch interposition reconstruction after total gastrectomy, an adequate procedure leads to nutritional advantage and prevents postoperative symptoms.