Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy

One-day nasogastric tube decompression after distal gastrectomy: a prospective randomized study

PURPOSE

Many surgeons in Japan use 1-day nasogastric tube (NGT) decompression after gastrectomy as a standard procedure. This prospective randomized study aimed to define whether 1-day NGT decompression is necessary after distal gastrectomy.

METHODS

The subjects were 233 patients with gastric cancer, randomized into two groups immediately after distal gastrectomy: one group received 1-day NGT decompression (NGT group, n = 119) and the other did not (no-NGT group, n = 114). The primary outcome measure was postoperative surgery-related and respiratory complications, whereas secondary measures were the postoperative course to recovery and patient complaints.

RESULTS

The incidence of surgery-related complications did not differ significantly between the NGT and no-NGT groups (21.0 and 19.2%, respectively; p = 0.87). The rate of respiratory complications was 6.7% in the NGT group and 7.0% in the no-NGT group (p > 0.99). The time to passage of first flatus and the postoperative hospital stay did not differ between the groups. Twenty-five patients in the NGT group and none in the no-NGT group complained of nasopharyngeal discomfort (p < 0.0001).

CONCLUSION

Considering the physical discomfort caused by the NGT, we believe that routine 1-day NGT decompression is unnecessary after distal gastrectomy.

Acupressure improves the postoperative comfort of gastric cancer patients: A randomised controlled trial

OBJECTIVE

This pilot study evaluated whether acupressure affected the postoperative comfort of gastric cancer patients following a subtotal gastrectomy.

METHODS

A randomised controlled trial was conducted. Sixty patients were recruited from 141-bed general surgery ward at a 3000-bed medical centre in Northern Taiwan. Participants were randomly assigned to either a control group receiving regular postoperative care or to the experimental group receiving additional acupressure at acupoints of Neiquan (P6) and Zusanli (ST36) for 3 consecutive days.

RESULTS

The similarities between two groups were in postoperative pain and the onset of postoperative nausea and vomiting (PONV) at the baseline. Following acupressure, significant differences were found in postoperative pain (P=.03) and time of first flatus (P=.04); but not PONV (P=.49), nor the time of first defecation (P=.34).

CONCLUSIONS

Acupressure is a simple, noninvasive, safe, and economical procedure for improving the comfort of patients who undergo surgery for gastric cancer. Acupressure at the P6 and ST36 acupoints can improve postoperative comfort by alleviating pain and decreasing the time until first flatus. However, additional research is necessary to elucidate how acupressure can improve postoperative outcomes.

Numerical and experimental analysis of factors leading to suture dehiscence after Billroth II gastric resection

The main goal of this study was to numerically quantify risk of duodenal stump blowout after Billroth II (BII) gastric resection. Our hypothesis was that the geometry of the reconstructed tract after BII resection is one of the key factors that can lead to duodenal dehiscence. We used computational fluid dynamics (CFD) with finite element (FE) simulations of various models of BII reconstructed gastrointestinal (GI) tract, as well as non-perfused, ex vivo, porcine experimental models. As main geometrical parameters for FE postoperative models we have used duodenal stump length and inclination between gastric remnant and duodenal stump. Virtual gastric resection was performed on each of 3D FE models based on multislice Computer Tomography (CT) DICOM. According to our computer simulation the difference between maximal duodenal stump pressures for models with most and least preferable geometry of reconstructed GI tract is about 30%. We compared the resulting postoperative duodenal pressure from computer simulations with duodenal stump dehiscence pressure from the experiment. Pressure at duodenal stump after BII resection obtained by computer simulation is 4-5 times lower than the dehiscence pressure according to our experiment on isolated bowel segment. Our conclusion is that if the surgery is performed technically correct, geometry variations of the reconstructed GI tract by themselves are not sufficient to cause duodenal stump blowout. Pressure that develops in the duodenal stump after BII resection using omega loop, only in the conjunction with other risk factors can cause duodenal dehiscence. Increased duodenal pressure after BII resection is risk factor. Hence we recommend the routine use of Roux en Y anastomosis as a safer solution in terms of resulting intraluminal pressure. However, if the surgeon decides to perform BII reconstruction, results obtained with this methodology can be valuable.

Naso-gastric or naso-jejunal decompression after partial distal gastrectomy for gastric cancer. Final results of a multicenter prospective randomized trial

BACKGROUND

Only a few, small, monocentric randomized controlled trials (RCTs) have compared routine vs. no placement of a nasogastric or nasojejunal tube decompression (NG/NJT) in patients undergoing partial distal gastrectomy (PDG) for gastric cancer. However, to our knowledge, no multicenter prospective RCT has analyzed the role of decompression after both the Billroth II (BII) procedure and Roux-en-Y (RY) gastrojejunostomy. The aim of this study was to determine whether NG/NJT prevents the consequences of postoperative ileus after PDG for gastric cancer after both BII reconstruction and RY.

METHODS

Two hundred seventy patients undergoing PDG for gastric cancer were randomly assigned NG/NJT placement (NG/NJT group) or not (no-NG/NJT group) with either Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy. The patients were monitored for postoperative complications, mortality, and postoperative course.

RESULTS

By January 2010 to June 2012, among 270 patients undergoing PDG for gastric cancer, 134 were randomly assigned to NG/NJT placement (NG/NJT group) and 136 to no decompression (no-NG/NJT group). Time to passage of flatus was significantly shorter in the NG/NJT group than in the no-NG/NJT group, but only after RY reconstruction (3.3 ± 1.5 vs. 4.3 ± 1.6 days, P < 0.001, respectively). Postoperative abdominal distention was significantly lower in the NG/NJT group than in the no-NG/NJT group after both BII and the RY procedure (P < 0.001). No significant differences in postoperative mortality or morbidity, especially anastomotic leakage or intra-abdominal sepsis, were observed between the groups.

CONCLUSION

Routine placement of an NG/NJT after BII and RY PDG is not necessary in elective surgery for gastric cancer.

Gastric cancer surgery without nasogastric decompression

Nasogastric decompression (ND) has been used worldwide in gastric cancer surgery as a traditional way since Hunter pioneered. Most surgeons believe that using ND in abdominal surgery could relieve the internal pressure of anastomosis and reduce the incidence of anastomotic leakage. However, there has no strict scientific evidence for this obtained from medical studies, especially prospective studies. In recent years, several studies have shown that routine use of ND after surgery could not prevent anastomotic leakage or accelerate the recovery of bowel function, and surgery without ND did not increase the risk of anastomotic leakage. All kinds of gastric cancer surgery could be performed safely without ND, which greatly reduces the suffering of the patients, accelerates postoperative recovery, and reduces the workload significantly. If patients with pyloric obstruction or bleeding receive ND before surgery, nasogastric tube could be removed after they waked up. Gastric cancer surgery without ND is safe and deserves clinical popularization. This review summarizes the safety and significance of gastric cancer surgery without ND.