New method for Billroth I reconstruction after distal gastrectomy

Authors report a new technique for Billroth I reconstruction after distal gastrectomy using linear stapling devices, which is easier than conventional methods. The duodenum is divided 0.5 cm distal to the pyrolus ring, with a 55-mm linear stapler. The anterior wall of the duodenum is cut along the planned line of anastomosis with the gastric remnant. The anterior wall of the stomach is cut along the planned suture line having a length similar to that of the duodenum. The posterior walls of the stomach and the duodenum are placed back to back on the planned anastomotic line. End-to-end posterior anastomosis between the gastric remnant and the duodenum is simultaneously performed with gastrectomy using a 100-mm linear stapler. End-to-end anterior anastomosis is performed by hand. This technique has been used in 7 patients, and there have been no complications related to this procedure. Operative time was 152 +/- 16 min (range 130 to 180 min) on average. It is an economical and easy procedure for Billroth I reconstruction.     

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.     

A novel reconstructive procedure after pancreaticoduodenectomy: J-pouch dunking pancreaticojejunostomy

Leakage of the pancreaticojejunostomy remains a major complication after pancreaticoduodenectomy. Several methods have been advocated in order to reduce anastomotic fistula but none of them reached a significant difference in preventing the leakage. We developed a new technique called "J-pouch dunking pancreaticojejunostomy". A "J" pouch is made from the distal 20 to 30 cm of jejunum by using a GIA linear stapler. A transverse incision is made on the jejunal base. As a result, we have enough jejunal stoma to anastomose the pancreatic remnant. A soft pancreas and small pancreatic size are known to be risk factors in pancreatic anastomosis. This technique is designed to eliminate the several factors related to pancreatic anastomotic leakage.     

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.     

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.     

Effect of the anastomosis-site after Billroth I gastrectomy on the motility of the remnant stomach

BACKGROUND/AIMS: Gastric emptying, in healthy individuals, is a highly regulated process, and plasma cholecystokinin plays a major role in its feedback regulation. However, the hormonal regulation of postprandial gastric emptying of the remnant stomach after distal gastrectomy with Billroth I reconstruction procedure has not been well described. The aim of this study is to characterize the gastroduodenal motility and gastric emptying of the two anastomosis-methods after Billroth I gastrectomy, while assessing the effect of cholecystokinin on the motility of the remnant stomach. METHODOLOGY: Two types of anastomosis (end-to-end, side (posterior wall)-to-end) after Billroth I gastrectomy were measured with strain gauge force transducers, and evaluated as to gastroduodenal motility, gastric emptying, gastrointestinal hormones (cholecystokinin, gastrin), and blood glucose associated with food administration. RESULTS: Remnant stomachs with side-to-end anastomosis showed superior motility as compared to those with end-to-end anastomosis. Plasma cholecystokinin was higher in the end-to-end anastomosis group. No differences as to gastric emptying, levels of plasma gastrin, or blood glucose were observed between the two groups. CONCLUSIONS: Plasma cholecystokinin may explain the difference in motility index between the two groups.     

Suture line recurrence in the jejunal pouch after curative proximal gastrectomy for gastric cancer: report of two cases

We report two patients with suture line recurrence in the jejunal pouch after curative proximal gastrectomy for gastric cancer. The first patient was a 60-year-old asymptomatic woman with gastric cancer (T2N0M0) after curative proximal gastrectomy with jejunal pouch interposition. She had to undergo a second resection for suture line recurrence in the jejunal pouch 12 months later. On examination of the resected specimen, histological examination revealed a moderately differentiated adenocarcinoma, which was similar to that of the primary tumor. The second patient was a 74-year-old man who was also diagnosed as having locoregional recurrences in the jejunal pouch after a curative proximal gastrectomy with an S-shaped pouch for gastric cancer (T2N0M0). Histological examination of the resected specimen revealed moderately differentiated adenocarcinoma, which had a similar histopathology to that of the primary tumor. During the first procedure, the jejunal pouch was formed using several disposable devices and the end-to-side esophagojejunostomy was performed with another circular stapler to avoid contamination through surgical instruments. Exfoliated cancer cells that may have detached from the primary tumor during the surgical procedures could have contributed to local recurrence along the longitudinal suture line of the pouch.     

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.     

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.     

Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis

We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.KEYWORDS : Laparoscopic, thoracoscopic, esophagectomy, esophagogastric anastomosis, esophageal carcinoma     

Marginal ulcer on the jejunum after proximal gastrectomy by jejunal interposition

Marginal ulcer after proximal gastrectomy has never been previously reported, despite that this procedure preserves the fundic gland area of the stomach, which secretes gastric acid. In this report, we describe a patient who developed a marginal ulcer on the oral side of the gastrojejunal anastomosis after proximal gastrectomy by jejunal interposition. This case serves as a reminder that gastric acid secretion of the remnant stomach must be carefully monitored after proximal gastrectomy in gastric cancer surgery.     

Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction

AIM： To compare postoperative quality of life （QOL） in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy. METHODS： QOL assessments that included functional outcomes （a 24-item survey about treatment- specific symptoms） and health perception （Spitzer QOL Index） were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy. RESULTS： Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty （EA group）; 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis （EP group）; and 50 patients had reconstruction by esophagogastric end-to-end anastomosis （EE group）. The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups. CONCLUSION： Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.     

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.     

Jejunal pouch interposition with an antiperistaltic conduit as a pyloric ring substitute after standard distal gastrectomy: a comparison with the use of an isoperistaltic conduit

BACKGROUND/AIMS: We performed jejunal pouch interposition with a short antiperistaltic conduit as a pylorus substitute after gastrectomy for gastric cancer and compared the outcome with an isoperistaltic conduit. METHODOLOGY: After a standard distal gastrectomy and lymph node dissection, a 15-cm-long pouch was formed using 3 linear staples (Endo-GIA) and interposed between the residual stomach and duodenum. The distal jejunal limb was made into a 3-cm-long isoperistaltic conduit in the isoperistaltic group (n = 17), and the proximal jejunal limb was made into a 3-cm-long antiperistaltic conduit in the antiperistaltic group (n = 8). Postoperatively, the patients were interviewed periodically to document any complaints. A dual-phase, dual-isotope radionuclide gastro-pouch-emptying study was performed 1 and 6 months after surgery. RESULTS: None of the patients developed postoperative complications and showed discomforts of dumping, stasis or reflux esophagitis. The dietary volume and body weight of patients gradually increased in both groups after 6 months. The combined radioisotope retention rate for the pouch and residual stomach was 31% for liquid food and 35% for solid food in the isoperistaltic group after 120 min, and 41% and 57%, respectively, in the antiperistaltic group. The pattern and emptying rate for solid food in the antiperistaltic group were more similar to those in healthy individuals than in the isoperistaltic group. CONCLUSIONS: The gastro-pouch-emptying test in the antiperistaltic group demonstrated acceptable emptying for a pyloric ring substitute. A reasonably good quality of life has been obtained for patients having an antiperistaltic jejunal conduit.     

Functional outcomes according to the size of the gastric remnant and type of reconstruction following open and laparoscopic proximal gastrectomy for gastric cancer

Background/Aims: We compared functional outcomes between different types of reconstruction following open or laparoscopic 1/2- or 2/3-proximal gastrectomy for gastric cancer. Methodology: Resection and reconstruction were performed by one of the following 6 methods, depending on the depth of cancer invasion and the date of the procedure relative to introduction of laparoscopic proximal gastrectomy: open proximal 2/3-gastrectomy with jejunal interposition (2/3PG-int, n=7), open proximal 1/2-gastrectomy with jejunal interposition (1/2PG-int, n=5), laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with small (3cm) jejunogastrostomy (L1/2 PG-DT(S), n=19) and laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with large (6cm) jejunogastrostomy (L1/2PG-DT(L), n=10). Open total gastrectomy with jejunal interposition (TG, n=12) and laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG, n=14) represented control procedures. Results: Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach and with easy flow of food into the remnant stomach (the 1/2PG-int and L1/2PG-DT(L) groups). Conclusions: Better functional outcomes were observed in patients with a large remnant stomach and with easy flow of food into the remnant stomach regardless of whether they underwent open or laparoscopic procedures.     

Serious complications after a proximal gastrectomy with a jejunal pouch interposition for gastric cancer

Proximal gastrectomy with jejunal interposition is a common surgical method in Japan, because the procedure has been shown to give a better post-operative quality of life. Some complications are associated with it. However, esophageal candidiasis and linear marginal ulcer along the gastrojejunal anastomosis after the surgical method has never previously been reported. We herein report a case of a patient who developed serious complications after proximal gastrectomy with jejunal interposition. A 68-year-old man underwent proximal gastrectomy with a jejunal pouch interposition for reconstruction for type 1 gastric cancer. Twenty-three months after the procedure, he complained of dysphagia and epigastric pain. Esophagogastroduodenoscopy showed esophageal candidiasis. The patient improved symptomatically following antifungal medication with fluconazole. Eleven months later, the patient developed severe pneumonia. In subsequent days, a melena episode occurred. Esophagogastroduodenoscopy revealed a linear marginal ulcer along three-fourths of the gastrojejunal anastomosis. The ulcer was drug resistant. The patient died of respiratory failure. Jejunal pouch interposition after a proximal gastrectomy can be associated with significant complications. Further studies are required to identify the best condition of the procedure.     

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.     

The affect of Helicobacter pylori and bile acids as the pathogenesis of gastritis of the remnant stomach after distal partial gastrectomy]

AIMS: After distal partial gastrectomy with Billroth I reconstruction, gastritis of the remnant stomach was previously considered to be caused by bile reflux. However, since in 1982, Helicobacter pylori (HP) was discovered and it was found that this organism caused for many types of stomach diseases. The affect of HP must also be examined in the remnant stomach. In a current study, we examined the existence of HP and explored bile reflux as a pathogenesis of gastritis of the remnant stomach after distal partial gastrectomy. PATIENTS AND METHODS: The subjects were 56 patients who underwent gastrectomy. The existence of HP was investigated before and after gastrectomy. At postoperative gastroscopy, we examined histological findings of remnant gastritis and total bile acid (TBA) concentration in the gastric juice. Then we assessed the effect of HP and TBA on gastritis regarding the time after gastrectomy. RESULT: HP was positive in 75% of the patients before the operation and in 37.5% after the operation. The HP positive ratio was significantly lower in patients more than 5 years after gastrectomy than in those within 5 years. Inflammatory cell infiltration of the remnant gastric mucosa was more prominent in HP positive patients than in HP negative patients. In HP positive remnant stomachs, the TBA concentration of the gastric juice was lower than in HP negative remnant stomachs. CONCLUSION: Within 5 years after distal partial gastrectomy, gastritis of the remnant stomach was mainly caused by HP.     

Long-term results show triple stapling facilitates safe low colorectal and coloanal anastomosis and is associated with low rates of local recurrence after anterior resection for rectal cancer

BACKGROUND: During low anterior resection (AR), placement of a staple line distal to an occlusion clamp is often difficult due to the confines of a narrow bony pelvis. This study reviewed the results of AR with a technique in which a linear staple line is fired below the tumour as an oncologically safe occlusion clamp. METHODS: Between 1995 and 2000, a total of 174 patients were operated for rectal cancer, and 153 of these patients had AR. Triple stapling (TS) was used to place a line of staples that occluded the fully mobilised rectum below a tumour. After rectal washout, a further linear stapler was applied below the first, and the rectum was divided prior to a standard circular stapled anastomosis. RESULTS: TS was performed in 127 (83%) of 153 patients undergoing AR, and 9 TS patients developed leaks (7%). In the whole series of 174 cases, 9 patients had local recurrence (5%), but the local recurrence rate for procedures classified as 'locally curative' was 2%. CONCLUSIONS: Triple stapling reliably occludes the rectum allowing for distal rectal washout. It eliminates clamp slippage and faecal spillage and improves access to the distal rectum for low anastomoses.     

The triple-stapled colonic anastomosis

This study reports the preliminary results of a new totally stapled end-to-end colonic anastomosis in 11 dogs. This "triple-stapled" end-to-end anastomosis was performed with one circular staple line and two linear staple lines, eliminating the need for a colotomy or purse-string suture. The fact that the anvil and anvil stem of a new circular stapling device (Premium EEA) can be detached from the frame of the instrument allows the anvil stem to be brought out through the proximal linear stapled colon. The trocar mounted on the main stem of the circular stapler allows the stem of the main device to be brought out through the distal staple line. Thus, a totally stapled colonic anastomosis is created after mating the anvil stem and main stem of the instrument. The new anastomosis was evaluated radiographically and at necropsy. The use of this technique resulted in no clinically detectable leaks, suggesting that it may facilitate the performance of anterior resections in humans.