Esophagogastrostomy reconstruction after limited proximal gastrectomy

BACKGROUND/AIMS: Recent advances in diagnostic techniques have led to the detection of an increasing number of early gastric cancers in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for these cancers. METHODOLOGY: The clinicopathologic characteristics of 35 patients with early gastric cancer in the upper third of the stomach who underwent three different types of gastrectomies were reviewed retrospectively from hospital records between January 1992 and August 1999. RESULTS: Patients undergoing limited proximal gastrectomy with esophagogastrostomy reconstruction had shorter operation times and less blood loss than those for patients undergoing total gastrectomy or proximal gastrectomy with jejunal interposition. No lymph node metastasis was identified in any of these patients. Heartburn due to reflux esophagitis was seen in a few patients of each group, but they were successfully treated by antacids. The extreme reduction in food intake volume was more frequently experienced in patients with total gastrectomy than those with both proximal gastrectomies. When mortality due to other disease was excluded, all patients survived without recurrence. CONCLUSIONS: A limited proximal gastrectomy with esophagogastrostomy reconstruction decreased surgical risk and realized preservation of maximal function.     

Comparison of nutrition and quality of life of esophagogastrostomy and the double-tract reconstruction after laparoscopic proximal gastrectomy

This study aims to compare the nutritional outcomes and quality of life between patients who underwent esophagogastrostomy (EG) and those who underwent the double-tract reconstruction (DTR) after laparoscopic proximal gastrectomy for early gastric cancer.We retrospectively reviewed the prospectively established database of 45 patients who underwent EG with anti-reflux procedure and 58 patients who underwent the DTR after laparoscopic proximal gastrectomy between December 2013 and June 2017. Then, we compared the baseline characteristics, clinical outcomes, postoperative nutritional parameters, and quality of life (QOL) using European Organization for Research and Treatment of Cancer (EORTC) QLQ STO-22 between the EG and DTR groups.In the postoperative 1-year endoscopic findings, the incidence of esophageal reflux was higher in the EG group (17.8% vs 3.4%, P = .041) and there was no significant difference in anastomotic stricture. Nutritional status was evaluated via body mass index, serum albumin, protein, hemoglobin, and ferritin; we found no significant differences. The incidences of iron deficiency anemia and vitamin B12 deficiency also showed no significant difference between the 2 groups. With regards to the quality of life, the difference values between preoperative and postoperative 1-year were evaluated; there was no significant difference between the EG with anti-reflux procedure and DTR groups.EG had higher incidence of esophageal reflux and similar nutritional outcomes and QOL compared with the double-tract reconstruction after laparoscopic proximal gastrectomy. Additional large-scale research is needed to evaluate the long-term functional outcomes of EG and the double-tract reconstruction.     

The nutritional advantages of proximal gastrectomy for early gastric cancer.

BACKGROUND/AIMS: Total gastrectomy has generally been performed for the treatment of early gastric cancers involving the upper third of the stomach. However, proximal gastrectomy has also been used for the treatment of cardial early gastric cancer. METHODOLOGY: To compare the nutritional parameters after proximal gastrectomy with the parameters after total gastrectomy, and to also determine the advantages of the postoperative nutritional states, a retrospective analysis was made to evaluate the nutritional status of patients with early gastric cancer who underwent proximal gastrectomy with those undergoing total gastrectomy. Forty-nine patients were studied for one year after surgery; 9 underwent proximal gastrectomy while 40 had a total gastrectomy. RESULTS: Proximal gastrectomy allowed the patient to better maintain both their nutritional parameters and body weight. CONCLUSIONS: Proximal gastrectomy was thus found to be a beneficial modality for early gastric cancer patients regarding terms of the postoperative nutritional status, in comparison to total gastrectomy.     

Evaluation of reconstruction after proximal gastrectomy: prospective comparative study of jejunal interposition and jejunal pouch interposition

BACKGROUND/AIMS: To prevent various distresses after proximal gastrectomy, reconstruction by interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to ensure favorable quality of life for the patients. METHODOLOGY: Proximal gastrectomy was performed in 9 patients with gastric cancer in the upper third of the stomach. Four patients were randomly selected for reconstruction by jejunal pouch interposition (JPI group), while 5 had reconstruction by jejunal interposition (JI group). The patients who underwent JPI and JI were followed up to evaluate resumption of normal diet, change in body weight, and clinical symptoms. RESULTS: The JPI group showed a significant dietary advantage. Three months after surgery, JPI patients could eat more than 80% of the volume of their preoperative meals, whereas JI patients ate less than 50%. The percentage of postoperative body weight loss was higher in the JI group than in the JPI group because the volume of the remnant stomach was more adequate in the latter. Moreover, it was easier to enter the remnant stomach and duodenum for endoscopic fiberscopy in the JPI group for the treatment of hepato-biliary pancreatic disease. CONCLUSIONS: JPI is an effective method for preservation of gastric function after proximal gastrectomy.     

Higher incidence of gastric remnant cancer after proximal than distal gastrectomy

BACKGROUND/AIMS: Proximal gastrectomy has been widely accepted as a standard operation for early stage gastric cancer located in the upper third of the stomach. Therefore, cancer of the distal gastric remnant is now increasing. The aims of this study were to clarify and compare the incidences of gastric remnant cancer after proximal and distal gastrectomy. METHODOLOGY: Data on a consecutive series of 809 cases of gastrectomy performed for early gastric cancer from 1991 to 2003 in Shikoku Cancer Center were analyzed retrospectively with respect to the incidence of gastric remnant cancer. RESULTS: We performed distal gastrectomy in 624 patients and proximal gastrectomy in 47 patients during the study period. After those operations, the gastric remnants of 457 cases and 33 cases, respectively, were surveyed periodically by endoscopic examination at our hospital. Among those surveyed cases, 10 patients (2.2%) and 3 patients (9.1%) were diagnosed as having gastric remnant cancer, respectively. The gastric remnant cancer-free survival after proximal gastrectomy was significantly lower than that after distal gastrectomy. CONCLUSIONS: Because of the higher incidence of gastric remnant cancer after proximal gastrectomy, it is more important to survey the gastric remnant after proximal gastrectomy periodically by postoperative endoscopic examination.     

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.     

Anti-reflux pouch-esophagostomy after proximal gastrectomy with jejunal pouch interposition reconstruction

Reflux esophagitis is a serious postoperative complication for patients undergoing gastrectomy. We designed a new jejunal pouch-esophagostomy to prevent reflux after proximal gastrectomy. After proximal gastrectomy, ajejunal segment about 17 cm long was folded. Side-to-side jejuno-jejunostomy was made using a linear stapler with 100-mm staples along the length at the anti-mesenteric side. A 10-cm-longjejunal pouch with a 7-cm-long apical bridge was made. Esophago-jejuno end-to-side anastomosis (pouch-esophagostomy) was made with circular stapler at the right anterior wall the apical bridge. We add "partial posterior fundoplication" like wrapping using the apical bridge of the jejunal pouch. Patients with this new anti-reflux anastomosis showed no reflux on barium meal study even in the right anterior oblique deep Trendelenburg's position. Jejunal pouch reconstruction with partial posterior wrapping provides a satisfactory result with regard to preventing reflux esophagitis.     

Modified Operation to Treat Types II and III Adenocarcinoma of the Esophagogastric Junction

Background/Aims: To study the effects of a gastric tube anastomosis in the intraperitoneal operation for types II and III adenocarcinoma of the esophagogastric junction (AEG). Methodology: Thirty-one patients with types II and III AEG were selected for proximal gastrectomy. After the proximal gastrectomy by the abdominal approach, the gastric remnant was cut into a tubular shape. The esophagus was then anastomosed to the gastric tube. Results: The surgical technique was performed on all 31 patients with types II or III AEG. The operation time was 279.52±34.99min, average surgery blood loss was 209.68±185.82mL, the number of hospital postoperative days was 10.48±2.01. All cases were followed-up for 2-12 months. One (3.2%) patient had postoperative anastomotic bleeding and another case had intractable hiccups. Only 3 (9.7%) patients felt heartburn after the operation. One (3.2%) patient was found to be suffering from reflux esophagitis through endoscopic examination. In addition, 1 (3.4%) patient had tumor recurrence. Conclusions: Using gastric tubes is a safe surgical technique and is followed by only a small number of complications at the early postoperative stage.     

Surgical attempts to avoid anastomotic leaks and reduce reflux esophagitis following esophagectomy for cancer

Background  We analyzed the results of our surgical attempts to establish a safe reconstruction after esophagectomy for cancer that withstands both early and subsequent complications. Methods  Patients who underwent an intrathoracic or cervical esophagogastrostomy were selected. We preserved the esophagus keeping an oral margin of at least 3 cm and made an anastomosis with the gastric wall as low as possible to avoid an anastomotic leak. We included an antireflux procedure in the intrathoracic anastomosis. We examined the effect of these surgical approaches in three patient groups: one group with cervical anastomosis (CA group, n = 21), and the other two groups with intrathoracic anastomosis after resection of cancer in the upper or middle thoracic esophagus (UM group, n = 104) or in the lower thoracic or abdominal esophagus (LA group, n = 30). Results  No leak was found in the esophagogastric anastomosis in any group. A gastric suture line dehiscence developed in two cases in the UM group. Postoperative endoscopy revealed that mean anastomotic height in the UM group was 4.1 cm lower than in the CA group (P < 0.0001) and 2.1 cm higher than in the LA group (P = 0.0006). The incidence of reflux esophagitis was 0% in the CA group, 43% in the UM group, and 37% in the LA group, with significant differences between the CA group and the other groups. Conclusions  Our surgical attempts to avoid leaks of esophagogastrostomy were entirely successful. An intrathoracic anastomosis combined with an antireflux procedure was not advantageous for the incidence of reflux esophagitis compared to cervical anastomosis, but it minimized the effects of anastomotic height on the development of reflux esophagitis.     

Ivor-Lewis esophagectomy for esophageal cancer after distal gastrectomy

We report the use of gastric remnant for esophageal substitution after distal gastrectomy in a 53-year-old man with esophageal cancer. This patient had a 4-month history of progressive dysphagia for solid food. An upper gastrointestinal endoscopy showed a 7.0 cm bulge tumor in the middle-lower esophagus, wherein the upper margin was located 28 cm from the dental arcade. Computed tomography (CT) of the chest revealed wall thickening in the middle-lower esophagus. In this case, radical en bloc esophagectomy with a two-field lymph node dissection was performed in the upper abdomen and mediastinum via a posterolateral right thoracotomy through the fifth intercostal space. Esophagogastric anastomosis was performed mechanically in the apex of the chest using a circular stapler. The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the right thoracic cavity. The patient was discharged on the 12th postoperative day without complications. The gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

Subcutaneous esophagojejunal reconstruction in the management of esophagogastric anastomotic leak: a staged procedure

Rupture of the esophagogastric anastomosis is potentially lethal if untreated. We report a case of esophagogastrostomy disconnection after an upper partial gastrectomy for strangulated paraesophageal hernia. The patient, a 50-year-old woman, developed systemic sepsis due to rapid manifestation of suppurative mediastinitis followed by peritonitis and was admitted to the intensive care unit 8 days after the primary operation. The patient underwent a staged surgical treatment and survived after a prolonged hospital stay. Initial reoperation consisted of emergent laparotomy and right thoracotomy for drainage and debridement completed with excision of the anastomosis, gastric stump exclusion and subcutaneous presternal transposition of the esophagus performed through a left cervical incision. Delayed restoration of the continuity of the gastrointestinal tract was re-established using jejunum. The final result achieved was a successful esophagojejunal anastomosis with both organs transposed in a subcutaneous presternal canal. The patient regained normal swallowing function. The 'subcutaneous esophageal transposition' procedure enables the easy performance of an extrathoracic esophagojejunal anastomosis and results in a safe gastrointestinal tract reconstruction in cases with esophagogastric anastomotic leakage.     

Esophageal reconstruction with remnant stomach:A case report and review of literature

The number of patients developing esophageal cancer after gastrectomy has increased.However,gastric remnant is very rarely used for reconstruction in esophageal cancer surgery because of the risk of anastomotic leakage resulting from insufficient blood flow.We present a case of esophageal cancer using gastric remnant for esophageal substitution after distal gastrectomy in a 57-year-old man who presented with a 1-month history of mild dysphagia and a background history of alcohol abuse.Gastroscopy showed a 1.2 cm × 1.0 cm bulge tumor of the lower third esophagus with the upper margin located 39 cm from the dental arcade.Computed tomography of the chest showed lower third esophageal wall thickening.The patient underwent en bloc radical esophagectomy with a two-field lymph node dissection of the upper abdomen and mediastinum via a left-sided posterolateral thoracotomy through the seventh intercostal space.The upper end of the esophagus was resected 5 cm above the tumor.The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the left thoracic cavity.The patient started a liquid diet on postoperative day 8 and was discharged on the 10 th postoperative day without complications.In this report,we demonstrate that the gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

Postoperative evaluation of the jejunal pouch reconstruction following proximal and distal gastrectomy for cancer

BACKGROUND/AIMS: To evaluate the efficacy of the jejunal pouch reconstruction following subtotal proximal and distal gastrectomy, a retrospective study examining the postoperative condition of patients who underwent different methods of reconstruction after gastrectomy for cancer was undertaken. METHODOLOGY: Various parameters indicative of postoperative function were evaluated at one year postoperatively, and two major groups were examined. The "proximal gastrectomy" group was composed of patients who underwent either 1) proximal gastrectomy with an interposed jejunal pouch (PG-pouch), 2) proximal gastrectomy with simple jejunal interposition (PG-inter), or 3) total gastrectomy with simple jejunal interposition (TG). The "distal gastrectomy" group was composed of patients who underwent either 4) distal gastrectomy with an interposed jejunal pouch (DG-pouch), 5) distal gastrectomy with simple jejunal interposition (DG-inter), or 6) distal gastrectomy with Billroth 1 reconstruction (B-1). RESULTS: Volume of meal intake was better preserved and the incidence of abdominal symptoms were less frequent in the PG-pouch and DG-pouch groups. In the PG-inter, DG-inter and DG-pouch groups, none of the patients experienced heartburn or had endoscopic findings consistent with reflux esophagitis, while 2 patients (20.0%) in the PG-pouch group complained of heartburn with evidence of reflux esophagitis on endoscopy. Increase in blood acetaminophen level was milder in both the PG-pouch and DG-pouch groups, signifying improved gastric emptying. CONCLUSIONS: The jejunal pouch interposition following proximal and distal gastrectomy seems to confer clinical benefit in terms of postoperative function, especially in the form of meal intake, abdominal symptoms, and gastric emptying. The side effect of an improved reservoir may be the incidence of reflux esophagitis seen in 2 patients in the PG-pouch group.     

Gastric tube reconstruction reduces postoperative gastroesophageal reflux in adenocarcinoma of esophagogastric junction

Background  

The anastomosis of gastric remnant to esophagus after proximal gastrectomy is the traditional surgical treatment procedure for patients with types II and III adenocarcinoma of esophagogastric junction. However, the postoperative complications such as gastroesophageal reflux are frequent.     

Lymph node dissection in surgical treatment for remnant stomach cancer

BACKGROUND/AIMS: Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy are obscure. There is consequent controversy about appropriate lymph node dissection in such cases. METHODOLOGY: Thirty-three consecutive patients with remnant stomach cancer and 44 consecutive patients primary gastric cancer in the upper third of the stomach were investigated retrospectively about lymphatic flow by injection of activated carbon particles, and about the incidence of lymph node metastasis. RESULTS: Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy without lymph node dissection were the same as those in primary gastric cancer in the upper third of the stomach. Lymphatic flow after distal gastrectomy with lymph node dissection frequently streamed toward the para-aortic lymph nodes through the lymph nodes along the greater curvature and the suprapancreatic lymph nodes. Lymphatic flow toward the jejunal and colonic mesentery was observed regardless of the method of reconstruction. This lymphogenesis was clearly observed, especially in patients with tumors invading the anastomosis site of Billroth-II reconstruction. Station Nos. 110 (lower paraesophageal) and 111 (supradiaphragmatic) lymph nodes were also stained, despite being considered sites of distant metastasis irrespective of the method of reconstruction. CONCLUSIONS: On the basis of the evidence of altered lymphatic flow and the incidence of lymph node metastases in remnant stomach cancer, left upper abdominal evisceration with para-aortic lymph node dissection should be performed in advanced remnant stomach cancer.     

Esophagogastric anastomosis with invagination into stomach: New technique to reduce fistula formation

AIM: To present a new technique of cervical esophagogastric anastomosis to reduce the frequency of fistula formation. METHODS: A group of 31 patients with thoracic and abdominal esophageal cancer underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube. In the region elected for anastomosis, a transverse myotomy of the esophagus was carried out around the entire circumference of the esophagus. Afterwards, a 4-cm long segment of esophagus was invaginated into the stomach and anastomosed to the anterior and the posterior walls. RESULTS: Postoperative minor complications occurred in 22 (70.9%) patients. Four (12.9%) patients had serious complications that led to death. The discharge of saliva was at a lower region, while attempting to leave the anastomosis site out of the alimentary transit. Three (9.7%) patients had fistula at the esophagogastric anastomosis, with minimal leakage of air or saliva and with mild clinical repercussions. No patients had esophago- gastric fistula with intense saliva leakage from either the cervical incision or the thoracic drain. Fibrotic stenosis of anastomoses occurred in seven (22.6%) patients. All these patients obtained relief from their dysphagia with endoscopic dilatation of the anastomosis.CONCLUSION: Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula with mild clinical repercussions.     

A case of using the remnant stomach as substitute after esophagectomy for esophageal cancer with history of distal gastrectomy

A 63-year-old man who had a distal subtotal gastrectomy and retrocolic end-to-side gastrojejunostomy was admitted because of a mid-thoracic esophageal cancer. He underwent a two-stage subtotal esophagectomy and reconstruction using the remnant stomach without microvascular anastomosis. We preserved the splenic artery, splenic vein, and the short gastric artery. The remnant stomach was pulled up together with the pancreas through the anterior sternal route. The superiority of this technique is that microvascular anastomosis is not needed because a sufficient blood supply from the splenic artery and only two anastomoses are needed, compared with three or four anastomoses when using the colon. This technique is also likely to be safer for patients requiring an esophagectomy after a distal gastrectomy.     

A novel operative technique on proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter.

BACKGROUND/AIMS: This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter. METHODOLOGY: We have performed a new technique for reducing postgastrectomy sequelae such as reflux esophagitis, early dumping syndrome, and microgastria in early gastric cancer located in the proximal third of the stomach. The technique consists of proximal gastrectomy with preservation of the hepatic, pyloric, celiac branch of the vagal nerve, and abdominal esophagus (lower esophageal sphincter), and reconstruction by interposition of a jejunal J pouch. To reserve pyloric function, pyloroplasty can be omitted by preservation of the pyloric branch from the vagal nerve. To restore loss of reservoir function, the reconstruction is performed with an interposed jejunal J pouch. Sacrifice of the mesenteric arcades is kept to a minimum to preserve the autonomic nerve and blood flow in the mesentery. RESULTS: All of the patients who underwent this operation were able to eat an adequate amount of food at 6 months after surgery and they were satisfied with their postoperative status. And that, we have not experienced postgastrectomy disorders such the dumping syndrome and reflux esophagitis. CONCLUSIONS: Therefore, this method is useful for preventing the postoperative disorders in patients with early gastric cancer located in the proximal third of the stomach.     

Esophagogastrectomy without pyloroplasty

There is no consensus on the need for pyloroplasty after esophagectomy or proximal gastrectomy with an esophagogastrostomy and vagotomy. Arguments for routine pyloroplasty include prevention of postoperative delayed gastric emptying. Arguments against include prevention of postoperative dumping syndrome and bile reflux esophagitis. The purpose of this study was to assess clinical outcomes of patients undergoing esophagogastrectomy without routine pyloroplasty. All patients undergoing esophagogastrectomy or proximal gastrectomy with esophagogastrostomy from October 1996 to September 2002, inclusive were reviewed for age, gender, diagnosis, type of resection, pathology, short-term complications, long-term complications, remedial procedures performed, and postoperative gastric emptying scintigraphy. 58 patients were studied. Postoperative mortality was 6.9%, and anastomotic leak rate 12.1%. Eleven patients (19%) had symptomatic gastroparesis, two required pyloric balloon dilation and one a pyloroplasty. No patients complained of dumping symptoms; reflux requiring medical intervention occurred in seven (12.1%), and anastomotic stricture requiring dilation occurred in five (8.6%). Omitting a pyloroplasty does not lead to a high frequency of symptomatic delayed gastric emptying. Maintaining the pylorus may protect patients from dumping syndrome, and bile reflux esophagitis with its potential noxious effects on the remaining esophageal mucosa.     

Quality of life in patients with esophagojejunal anastomosis after total gastrectomy for cancer

OBJECTIVE: To analyze the influence of the esophagojejunostomy type (Roux-en-Y end-to-end or end-to-side, omega, manual or mechanic), of the associated resections and postoperative complications, on patients' Quality of Life (QoL) after total gastrectomy for cancer. METHODS: From 1997 to 2004 63 patients underwent a total gastrectomy for cancer. Patients were invited to fill a questionnaire with 14 treatment-specific related symptoms at 3 and respectively 12 months postoperatively. The present study comprises 39 patients, all without cancer recurrence, who completed all required items. RESULTS: The QoL was not influenced by the patients' age and gender, associated resections or by the esophagojejunostomy type. Anastomotic fistula significantly influenced patients' appetite at 3 months (p=0.013). At 12 months postoperatively there was a significant difference between the patients' body weight when end-to-end anastomosis were compared to end-to-side anastomosis (p=0.023). The patients' QoL improved in a significant manner at 12 months postoperatively, compared to their QoL at 3 months. CONCLUSIONS: After total gastrectomy for cancer, patients' QoL is not significantly influenced by the type of the esophagojejunostomy. The end-to-end esojejunal anastomosis seems to have a less deleterious effect on the postoperative weight loss. Anastomotic fistula remains the only complication with some influence on patients' QoL in the first postoperative months.