New method for jejunal pouch interposition reconstruction after distal gastrectomy

BACKGROUND/AIMS: Recently pouch reconstruction has been reported to improve quality of life and functional results after surgery for gastric cancer. Although jejunal pouch reconstruction after distal gastrectomy has favorable results for patients' quality of life, it is complicated and takes a long time to complete. We developed a new technique using a linear stapling device to avoid this problem. METHODOLOGY: The duodenum and the jejunum are simultaneously divided with a 100-mm linear stapler 0.5 cm distal to the pyrolus ring and 20 cm distal to the ligament of Treitz, respectively. A 100-mm linear stapler is introduced into two approximated segments of the jejunum through two small stab wounds 10 cm and 15 cm distal to the stump, respectively, and side-to-side anastomosis is performed along the antimesenteric borders. The anterior wall of the pouch is cut along the prospective 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 pouch. The posterior walls of the stomach and the jejunal pouch are placed back-to-back on the planned anastomotic line. End-to-end posterior anastomosis between the gastric remnant and the jejunal pouch is simultaneously performed with gastrectomy using a 100-mm linear stapler. End-to-end anterior anastomosis is created by hand. RESULTS: This technique has been used in 4 patients, and there have been no complications related to the pouch or anastomoses. Mean operative time was 255 +/- 37 min (range: 205-290 min). CONCLUSIONS: Shortening of operative time can be attributed to adoption of end-to-end posterior anastomosis between the stomach and the jejunal pouch using the linear stapling device simultaneously with gastrectomy.     

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.     

Long-term follow-up of patients with jejunal pouch reconstruction after total gastrectomy. A randomized prospective study

BACKGROUND: Fifty-one patients were operated on during 1988-1992 and randomized after total gastrectomy to one of two reconstruction types. Twenty patients with jejunal pouch reconstruction and 14 patients with Roux-en-Y reconstruction (67% of all) survived at least 3 years after total gastrectomy. We studied symptoms, eating capacity, and nutrition in these patients during the clinical follow-up; 21 patients were assessed by mail questionnaire 8 years after total gastrectomy. METHODS: Postoperative symptoms, number of meals, and eating capacity were assessed by standard questionnaire during 3 years' follow-up. Weight loss and nutritional laboratory variables were measured, and upper intestinal endoscopy with biopsy was performed during the follow-up. Eight years after the operation symptoms, ability to eat, and number of meals consumed were studied by means of a mail questionnaire. RESULTS: Three years postoperatively dumping (64% compared with 10%, P < 0.05) and early satiety (86% compared with 5%, P < 0.05) were commoner in the Roux-en-Y group. In the pouch group eating capacity was better (96% of normal compared with 67%, P < 0.05), and the patients ate fewer meals per day (mean, 2.7 versus 5.3, P < 0.05) at 3 years. Mean weight loss at 3 years was 9.9 kg in the Roux-en-Y group compared with 1.5 kg in the pouch group (P < 0.05). 25 (OH) vitamin D concentration tended to be higher in the pouch group (47.3 nmol/l compared with 33.9 nmol/l). In the Roux-en-Y group serum alkaline phosphatase activity increased significantly during the 3 postoperative years (from mean 163 U/l to 248 U/l, P < 0.01) and tended to be higher (248 U/l compared with 216 U/l in the pouch group). None of the patients developed oesophagitis or pouchitis during the follow-up. One patient developed a bezoar in the pouch 5 years after gastrectomy. CONCLUSIONS: Pouch reconstruction after total gastrectomy is associated with diminished postoperative symptoms, better eating capacity, and decreased weight loss compared with Roux-en-Y reconstruction. Jejunal pouch reconstruction is thus the recommended surgical method after 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.     

An experimental study of jejunal pouch replacements following total gastrectomy

BACKGROUND/AIMS: The nutritional effects of pouch replacement after total gastrectomy remain clinically controversial. Two previous experiments failed to show any nutritional benefit. However, the pouches applied clinically and examined experimentally so far were all of anti-peristaltic type. METHODOLOGY: Male 7- or 8-week-old Wistar rats were divided into 3 experimental groups after total gastrectomy. For group 1 and 2 rats, Roux-en-Y reconstructions and Hunt-Lawrence pouches, i.e., anti-peristaltic type, were performed, respectively. Group 3 rats underwent a new type of iso-peristaltic pouch replacement. Food intake was recorded daily and all rats were weighed once a week. At the end of the 12-week experimental period, there were 9 rats in group 1, 10 in group 2, and 8 in group 3. The volumes of the gastric reservoirs were measured, and blood samples were taken. Five 20-week-old rats served as control of weight, food intake, and laboratory data. RESULTS: The volumes of the gastric reservoirs in group 2 and 3 rats were significantly larger than in group 1 animals. However, there were no intergroup differences in weight change or food intake. The weights and the food intakes of the 3 experimental groups were significantly lower than those of the control rats. No superiority in the results of blood samples was observed among the experimental groups. Correlations between weight gain and food intake were shown in all groups. But, a correlation between the volume of the gastric reservoir and food intake was observed only for group 3 rats. CONCLUSIONS: The present study showed no nutritional benefits of an iso- as well as an anti-peristaltic pouch replacement.     

Complication of jejunal pouch interposition after proximal gastrectomy: case report

Interposition of a jejunal pouch after proximal gastrectomy is a popular reconstruction method in Japan, because it produces a good quality of life soon after surgery. Many reports have described its usefulness. However, there are few reports describing its complications. We report here for the first time a case of pouch stasis needing surgery. A 23-year-old man underwent proximal gastrectomy with interposed jejunal pouch for traumatic strangulated diaphragmatic hernia. Three years later, he complained of persistent vomiting. Since surgery, he had eaten as much as other young people. An upper gastrointestinal series showed dilatation of the jejunal pouch and stasis of contrast medium. Since conservative therapy was not effective, surgery was performed. In the operative findings, the jejunal pouch was extremely dilated, the remaining stomach had become atrophic, and moreover, the anastomosis was severely distorted. It was considered that frequent excessive ingestion caused irreversible dilatation of the jejunal pouch, resulting in pouch stasis. Even though the jejunal pouch is interposed for reconstruction, it is very important to give nutritional guidance to patients, especially young patients, to prevent pouch stasis caused by excessive food ingestion.     

Pouch size influences clinical outcome of pouch construction after total gastrectomy:A meta-analysis

AIM:To assess the clinical significance of pouch size in total gastrectomy for gastric malignancies.METHODS:We manually searched the English-language literature in PubMed,Cochrane Library,Web of Science and BIOSIS Previews up to October 31,2013.Only randomized control trials comparing small pouch with large pouch in gastric reconstruction after total gastrectomy were eligible for inclusion.Two reviewers independently carried out the literature search,study selection,data extraction and quality assessment of included publications.Standard mean difference(SMD)or relative risk(RR)and corresponding 95%CI were calculated as summary measures of effects.RESULTS:Five RCTs published between 1996 and2011 comparing small pouch formation with large pouch formation after total gastrectomy were included.Eating capacity per meal in patients with a small pouch was significantly higher than that in patients with a large pouch(SMD=0.85,95%CI:0.25-1.44,I2=0,P=0.792),and the operative time spent in the small pouch group was significantly longer than that in the large pouch group[SMD=-3.87,95%CI:-7.68-(-0.09),I2=95.6%,P=0].There were no significant differences in body weight at 3 mo(SMD=1.45,95%CI:-4.24-7.15,I2=97.7%,P=0)or 12 mo(SMD=-1.34,95%CI:-3.67-0.99,I2=94.2%,P=0)after gastrectomy,and no significant improvement of postgastrectomy symptoms(heartburn,RR=0.39,95%CI:0.12-1.29,I2=0,P=0.386;dysphagia,RR=0.86,95%CI:0.58-1.27,I2=0,P=0.435;and vomiting,RR=0.5,95%CI:0.15-1.62,I2=0,P=0.981)between the two groups.CONCLUSION:Small pouch can significantly improve the eating capacity per meal after surgery,and may improve the post-gastrectomy symptoms,including heartburn,dysphagia and vomiting.     

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.     

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

Background:The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).Methods:A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.Results:Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.Conclusion:This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.     

New method of jejunal pouch reconstruction after selective vagotomy and antrectomy

Selective vagotomy and antrectomy (SV-A) is performed as a surgical treatment in patients with pyloric stenosis due to peptic ulcer. Since this method shows that the incidence of postoperative complaints is not low, various reconstruction methods have been evaluated to prevent the sequelae. However, there have been no definitely useful methods. A jejunal pouch reconstruction used for gastric cancer surgery has been performed to compensate for the disadvantages of SV-A in 7 patients with complicated gastric, duodenal ulcers at this study. A 10- to 15-cm-long pouch is interposed between the remnant stomach and the duodenum. The pouch is anastomosed to the duodenum using the double tract method. The median postoperative follow-up period was 61 months. No patients showed gastric stasis, ulcer recurrence, residual gastritis. We demonstrated the method of jejunal pouch double tract reconstruction after SV-A. This method was useful for preventing the sequelae after SV-A.     

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.     

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.     

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy for proximal gastric cancer with stage cT1–2

This study aimed to evaluate the feasibility and nutritional benefits of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) in comparison with laparoscopic total gastrectomy (LTG).The demographic, clinical, and pathological data and postoperative nutritional status of patients undergoing LPG with DTR (n = 21) or LTG (n = 26) at Sir Run Run Shaw Hospital between January 2016 and January 2019 were retrospectively reviewed and compared.The operative time in the LPG group was slightly longer than that in the LTG group; however, the difference was not statistically significant. Blood loss was not significantly different between groups. The mean number of retrieved lymph nodes was higher in the LTG group than in the LPG group (P = .02). The time to first flatus, postoperative hospital stay, and postoperative complications were comparable between the groups. During the 3-year postoperative follow-up, a statistically significant decrease in hemoglobin level was observed in the LTG group. There were no differences between the two groups of patients before and after the operation regarding albumin levels. The mean vitamin B₁₂ level was higher in the LPG group than in the LTG group from 12 to 18 months postoperatively.LPG with DTR is an acceptable procedure for patients with upper gastric cancer. LPG with DTR has numerous potential advantages in preserving the physiological and nutritional functions of the remnant stomach and the conservation of the gastric reservoir.     

Free jejunal pouch graft reconstruction after a resection of hypopharyngeal or cervical esophageal cancer.

BACKGROUND/AIMS: Pharyngoesophageal reconstruction using the free vascularized jejunal graft sometimes results in dysphagia and this may be caused by anastomotic stenosis at either the distal or proximal anastomotic site, graft contractility and the entrapment of food in the blind loop after an end-to-side pharyngojejunostomy. We therefore applied pouch procedures to the free jejunal graft in order to improve the ability for such patients to consume normal food. METHODOLOGY: We performed this procedure on 4 patients with pharyngoesophageal cancer located within the cervical regions. RESULTS: As a result, the following post-operative complications occurred in 1 case each: anastomotic leakage at the pharyngojejunostomy (proximal anastomosis) which healed spontaneously, and anastomotic stenosis in jejunoesophagostomy (distal anastomosis) which improved after performing endoscopic dilatation. CONCLUSIONS: However, these complications were not thought to be due to the pouch procedures and the passage of food was found to be excellent in all cases at the time of discharge.     

Antiperistaltic duodenojejunal pouch in the reconstruction of digestive transit after subtotal, total gastrectomy and in the postgastrectomy syndrome. Technic

A new technic for reconstruction of the digestive tract after total and subtotal gastrectomy in patients with BII postgastrectomy syndrome is proposed. This technic is based on: 1) the to-and-from motion of the barium inside the duodenal arch, and 2) the duodenogastric reflux, both observed in X-ray examinations in normal and in patients bearing gastroduodenal ulcers. The advantage of this technic is to associate the inverted Y en Roux with an interposition of a small bowel segment, besides a reservoir with dynamic function which is obtained using the duodenal arch, as well as 10 cm of jejunum, where the ingested food is mixed with the digestive secretions and is eliminated with antiperistalsis, without stasis. From 1977 to 1983, 36 patients were operated on with the above mentioned technic. Ten of them were admitted to total gastrectomy, 16 to subtotal gastrectomy, 7 to minimal radical gastrectomy and three to postgastrectomy syndrome.     

An antiperistaltic duodenojejunal pouch in the reconstruction of digestive transit after subtotal and total gastrectomy and in the postgastrectomy syndrome. Results

The author presents the results of a new surgical technique for the reconstruction of the gastrointestinal tract after gastrectomy. It was utilized in 36 patients (ten with total, 16 with subtotal and seven with minimal radical gastrectomy and also three cases of post-gastrectomy syndrome). The initial methodology, using the lost tie (group striction (GST)) to the duodenojejunal reservoir was not successful since it showed recanalization and consequent refluxing esophagitis (55,5%). For that reason, we changed to a complete section of the intestinal loop (group section (GS)). The follow up period ranged from one to 49 months. The following complications were observed: incisional hernia, one case (GST); early postoperative period death (19th day), one case (GS); dumping syndrome, one case (GST); bilious vomiting, two cases (GS); diarrhea, four cases (one GST and three GS). Clinically, in the late follow up of patients without recurrency of neoplasia, 17 of them have gained weight, four have lost weight and two were unaltered. Laboratory tests such as amilasemia, hematologic, proteins and glycemia were favorable to the method. Postoperative function, studied roentgenologically, showed that the average time emptying of the remmant stomach was 115 minutes in the subtotal resections and 82 minutes in total resections. The filling of the reservoir by the barium solution ranged from 40 to 60%; this variation depended on whether the duodenum was in peristalsis or antiperistalsis. Late death occurred in 13 patients, none because of the proposed technique.