Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience

Merendino Resection vs. Transhiatal Gastric Conduit After Resection of the Cardia and the Gastroesophageal Junction

BACKGROUND

Reconstruction after combined cardia resection and removal of the gastroesophageal junction can be carried out by the Merendino procedure or via a gastric conduit. This study compares postoperative complications and quality of life for both approaches.

METHODS

All patients who underwent Merendino or gastric conduit reconstruction from 2011-2017 were included. Both groups were investigated regarding postoperative length of stay, complications, and gastrointestinal quality of life.

RESULTS

45 patients were identified, of which, 39 remained for analysis: 22 patients in the Merendino group and 17 patients in the gastric conduit group. The median age of patients in the gastric conduit group (71 (53-92) years) was significantly higher than in the Merendino group (58 (19-75) years), P = .0002. Hospital stay was significantly longer in the gastric conduit group (35.9 (11-82) days vs. 18.2 (7-43) days, P = .0299) and incidence of anastomotic leakage was higher (24% vs. 9%, P = .0171). General incidence of complications (Clavien-Dindo) did not vary (P = .1694). However, grade 5 complications only occurred in the Merendino group (n = 1). Evaluation of long-term outcome and quality of life showed dysphagia to only have occurred in the Merendino group (n = 3, 14%).

DISCUSSION

Both approaches have advantages and disadvantages: The Merendino procedure showed reduced incidence of anastomotic leakage and shorter hospital stay but was associated with a higher in-hospital mortality rate. Discrepancies in subgroup populations as well as small patient numbers limit the interpretation of the findings. This study does however provide a first comparison of these surgical approaches and may serve as a basis for further investigation.

[Redo reconstruction of the digestive tract after gastric surgery]

OBJECTIVE

To formulate the concept of physiological reconstruction of the digestive tract during redo gastric surgery.

MATERIAL AND METHODS

There were 52 patients who underwent redo gastric surgery after previous resections, drainage and antireflux procedures in 2011-2017 at the Vishnevsky National Research Surgical Center. Redo resection of the stomach with Billroth-1 and Hofmeister reconstructions were performed in 5 (9.6%) and 1 patient (1.9%), respectively. Roux-en-Y reconstruction was performed in 4 (7.7%) patients after gastric remnant extirpation. Jejunogastroplasty was used in 30 (57.7%) patients. A segment of the transverse colon as the reconstructive material was used in 2 (3.8%) patients, left colon - in 8 (15.4%) after esophagectomy. One (1.9%) patient underwent extirpation of 'small' stomach and thoracic esophagus after previous gastric bypass. Gastric remnant was used as an isoperistaltic tube for subtotal esophagoplasty. Reconstruction was not possible in only 1 (1.9%) patient after advanced visceral resection for recurrent cancer within esophagojejunostomy due to deficit of visceral material.

RESULTS

Postoperative complications were observed in 5 (9.6%) patients. Partial failure of esophagojejunostomy and duodenojejunostomy occurred in 2 (3.8%) and 1 patient (1.9%), respectively. Colon transplant necrosis was noted in 1 (1.9%) patient that required resection followed by colo- and esophagostomy nutrition. One patient died on the 1^st postoperative day from progressive multiple organ failure. At the end of the study, 44 (86.2%) out of 51 patients were under follow-up. Good results were revealed in 26 (59.9%) patients, satisfactory outcomes - in 12 (27.4%) patients. Redo surgery was not effective in only 6 (13.7%) patients.

CONCLUSION

Evaluation of our results demonstrates complete alleviation of pathological postoperative syndromes after gastric surgery in the majority of patients. Therefore, redo surgery with gastroplasty and restoration of duodenal passage are advisable.