Robot-assisted total remnant gastrectomy for interposed jejunal pouch dysfunction 25 years after proximal gastrectomy for gastric cancer: A case report

Proximal gastrectomy (PG) in combination with jejunal pouch interposition is a technique aimed at improving the postoperative dietary outcomes; however, some cases are reported to require surgical intervention owing to difficulty of food intake caused by pouch dysfunction. Herein, we present a case of robot-assisted surgery for interposed jejunal pouch (IJP) dysfunction in a 79-year-old male, occurring 25 years after the initial PG for gastric cancer. The patient had chronic anorexia for 2 years and was treated with medications and dietary guidance; however, 3 months prior to admission his quality of life had reduced, owing to worsening symptoms. The patient was diagnosed with pouch dysfunction due to extremely dilated IJP identified using computed tomography and underwent robot-assisted total remnant gastrectomy (RATRG) with IJP resection. After an uneventful course of intraoperative and postoperative treatment, he was discharged with sufficient food intake on postoperative day 9. RATRG can, thus, be considered in patients with IJP dysfunction after PG.     

全胃切除术后两种常用消化道重建方式的比较

目的探讨全胃切除术合理的消化道重建方式。方法回顾分析我院1999—2008年所开展全胃切除手术病例,选择其中最常采用的P袢空肠Roux—en—Y重建术和功能性空肠间置吻合术,对其手术难度、术后病人的并发症及营养差异进行比较。结果两种手术方法手术难度、术后并发症相差不太。P袢空肠Roux—en—Y重建术后早期适应性较好;功能性空肠间置吻合术后病人后期营养优于前者。结论全胃切除后,P袢Roux—en—Y吻合术和功能性空肠间置吻合术在改善患者术后症状和生活质量等方面是比较理想的重建术式,但功能性空肠间置吻合术是一种更符合生理,更能解决全胃切除后病人发生营养障碍的术式。     

D2 gastrectomy -- a safe operation in experienced hands

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.     

全胃切除治疗胃恶性肿瘤(例44附报告)

本文报告华西医大普外科1981～1989.2月间作了全胃切除的胃恶性肿瘤44例,手术死亡率2.27％,近期并发症31.8％,主要为胸部并发症,吻合口漏只1例。对远期生存者作了消化吸收功能研究,多数病人代胃空物功能良好。本文讨论了①全胃切除的指征;②如何降低手术死亡率及远期并发症;③推荐Roux-n-y,P型空肠袢代胃术或P型空肠袢间置代胃术,两者均为合理的消化道重建方式。     

管型吻合器在经腹全胃切除P型空肠袢代胃术中的应用

目的：探讨管型吻合器在经腹全胃切除P型空肠袢代胃术中的应用。方法：对126例经腹全胃切除P型空肠袢代胃术患者术中采用管型吻合器行食管-空肠、空肠-空肠（P型袢）及空肠-空肠（Roux-Y）吻合口吻合。结果：所有患者手术均获成功，手术时间2～2．5h，平均3．5h，其中3个吻合口吻合完成时间25～50min，平均40min；无手术死亡病例，无吻合口瘘、出血及狭窄等严重并发症。结论：经腹全胃切除P形空肠袢代胃术中采用管型吻合器行3个吻合口吻合具有操作简便、技术可靠及并发症少等优点。     

Endoscopic surveillance for gastric remnant cancer after early cancer surgery

BACKGROUND AND STUDY AIMS: The aims of this article were to clarify the incidence of gastric remnant cancer after surgery for early gastric cancer, and to develop surveillance programs for patients who have undergone partial gastrectomy in order to detect such lesions at an early stage. PATIENTS AND METHODS: A total of 642 patients with partial gastrectomy for early gastric cancer were enrolled in a surveillance program for gastric remnant cancer between 1985 and 1996. In 509 patients, the interval between endoscopic examinations was no more than 2 years. RESULTS: Among the 509 patients examined periodically, 15 patients were diagnosed as having gastric remnant cancer; in 12 patients, the cancers were detected at an early stage. All gastric remnant cancers were found distant from the site of the anastomosis, and in eight patients the cancers were located on the lesser curvature. The cumulative 5-year prevalence rate was estimated as 2.4 % and the 10-year prevalence rate as 6.1 %. The initial tumors in the patients with gastric remnant cancer were of the microscopically intestinal type, without exception. The interval between the preceding examination and diagnosis was shorter in the patients with early cancer than in those with advanced cancer ( P < 0.01). CONCLUSIONS: Periodical surveillance endoscopy for gastric remnant cancer is recommended after surgery for early gastric cancer, particularly in patients whose cancers are of the intestinal type. The examinations can be repeated at 2 - 3-year intervals, and special attention should be given to the lesser curvature away from the anastomotic site.     

保留胃窦的间置空肠双通道术式在食管胃结合部癌根治术中的应用探讨

目的探讨保留胃窦的间置空肠双通道术式在食管胃结合部癌(AEG)根治术中的临床应用价值。方法对66例SiewertⅡ、Ⅲ型食管胃结合部癌,分别采取保留胃窦的间置空肠双通道术式(28例)和全胃切除Roux-en-Y空肠食管吻合术式(38例),回顾性分析对比两组手术患者在手术时间、出血量、术后肠功能恢复时间以及术后并发症发生率等方面有无差异。结果保留胃窦的间置空肠双通道术式组,与全胃切除Roux-en-Y空肠食管吻合术组对比,除在术后肛门排气时间和进食流质时间两个方面略有差异外,无论在手术时间、术中出血量、住院时间以及术后早期并发症的发生率均无明显差异。此外,保留胃窦的间置空肠双通道术式组在术后的反流性食管炎发生也要低于全胃切除Roux-en-Y空肠食管吻合术组。随访6¹8个月,患者近期生活质量满意。结论保留胃窦的间置空肠双通道术式,因残胃有一定储袋作用,且进食具备双通道路径,能较好地预防反流性食管炎和倾倒综合征。同时,保留了十二指肠路径,能有效刺激胆汁分泌,降低胆结石的发生率。此外,此术式清扫、切除范围合理,手术创伤相对较小,是SiewertⅡ、Ⅲ型AEG根治术较理想的消化道重建方式之一。     

食管空肠Roux-en-Y吻合与间置空肠代胃在胃癌根治术后的应用效果比较

目的比较食管空肠Roux-en-Y吻合与间置空肠代胃在胃癌根治术后的应用效果及对患者消化道功能恢复的影响。方法将63例早期近端胃癌患者根据吻合方法不同分为A组(n=33)和B组(n=30)。A组给予根治性近端全胃切除+食管空肠Roux-en-Y吻合术,B组给予根治性近端胃大部切除+食管残胃间置空肠代胃治疗。比较两组的手术指标、术后胃肠功能恢复指标、营养状况、血清胃肠激素水平、胃肠道症状评分和并发症发生情况。结果B组的手术时间长于A组,消化道重建时间、肠鸣音恢复时间、肛门排气时间、术后首次进流食时间、住院时间均短于A组,术中出血量少于A组,淋巴结清扫数目多于A组(P<0.05)。术后10 d,两组的血红蛋白、总蛋白、血清胃泌素、胃动素水平均低于术前,但B组高于A组(P<0.05);术后半年,两组的血红蛋白、总蛋白水平高于术后10 d,血清胃泌素、胃动素水平低于术后10 d,但B组均高于A组(P<0.05)。术后3、6个月,两组的胃肠道症状评分均低于术前,且B组低于A组(P<0.05)。两组的并发症总发生率无显著差异(P>0.05)。结论根治性近端胃大部切除+食管残胃间置空肠代胃治疗胃癌患者,可明显改善消化道功能,提高术后营养状况,且对胃肠激素水平影响较小。     

Total proctocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks

Background: To assess the role of contrast enemas for the evaluation of leaks in symptomatic and asymptomatic patients after the first stage of restorative proctocolectomy. Methods: We reviewed the findings of 59 contrast enemas in 40 patients who underwent total proctocolectomy with creation of an ileoanal pouch and a proximal diverting ileostomy. Thirty-seven patients initially underwent routine contrast studies of the ileoanal pouch, and three underwent contrast studies because of suspected fistulas or obstruction. Medical records were also reviewed to determine the clinical presentation and course of these patients. Results: Of 37 patients who underwent routine postoperative contrast enemas, 33 (89%) had normal studies, three (8%) had clinically silent leaks (including two blind-ending tracks from the ileoanal anastomosis and one from the pouch), and one (3%) had pouchitis. In all three patients with unsuspected leaks, ileostomy closure was delayed. In two other patients with abdominal pain and fever, contrast enemas revealed leaks from the ileoanal pouch and distal ileum, respectively. The remaining patient had a contrast enema because of abdominal pain and distention; this patient had a distal ileal obstruction due to adhesions. Conclusions: Routine postoperative contrast studies revealed clinically silent leaks from the ileal J pouch or ileoanal anastomosis in three of 37 patients (8%) after the first stage of restorative proctocolectomy. Our findings suggest that routine contrast enema can detect clinically silent leaks after this surgery. Received: 31 January 1997/Accepted: 5 March 1997     

Robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy

The utility of robotic surgery for remnant gastric cancer remains unclear. We report a case of a robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy and Child reconstruction with Braun enteroenterostomy. Adhesiolysis, lymphadenectomy, and gastrectomy were robotically performed. Indocyanine green fluorescence imaging confirmed the tissue perfusion of the reconstructive tract. The patient's postoperative course was uneventful. Robotic surgery facilitates safety for gastrectomy after pancreaticoduodenectomy because of its precise manipulation; its advantages can be further exploited by maximizing usage of the assistant's forceps. Indocyanine green fluorescence imaging capability of the da Vinci Xi Surgical System allows timely evaluation of tissue perfusion at the site of interest, leading to a more reliable procedure.     

术中联合胃镜测漏对预防胃癌患者术后吻合口并发症的影响

目的 对比术中联合胃镜的充气测漏和亚甲蓝测漏技术对胃癌根治术患者术后吻合口并发症的影响.方法 回顾性分析2017年9月-2019年9月南充市中心医院207例行胃癌根治术患者的临床和病理资料.根据是否使用术中测漏(IOLT),将患者分为IOLT组和无术中测漏(NIOLT)组.术中测漏包括胃镜检查、充气测漏和亚甲蓝测漏.分...     

3D腹腔镜平行重叠吻合联合经自然腔道取标本在近端胃癌根治术中的应用价值

目的 观察女性近端胃癌患者3D腹腔镜根治术中行平行重叠吻合法消化道重建,并经自然腔道取标本在淋巴结清扫、术后胃肠功能恢复中的作用,探讨其治疗效果及安全性.方法 女性近端胃癌患者36例,其中16例行3D腹腔镜近端胃癌根治术,术中行平行重叠吻合法消化道重建,并经自然腔道取标本者为观察组;20例行2D腹腔镜近端胃癌根治术,术...     

Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy

BACKGROUND AND STUDY AIMS: We aimed to study the technical feasibility, safety, efficacy and complications of endoscopic feeding tube placement in patients who had previously undergone subtotal gastrectomy. We also investigated whether jejunal feeding tube placement (percutaneous endoscopic jejunostomy [PEJ]) is superior to gastric feeding tube placement (percutaneous endoscopic gastrostomy [PEG]) in the prevention of aspiration pneumonia in patients with subtotal gastrectomy. PATIENTS AND METHODS: A retrospective cohort study was carried out which included 48 patients treated between 1995 and 2001. Participants were selected from 3400 patients who were referred for PEG placement. The study group consisted of 15 consecutive patients with a prior subtotal gastrectomy. The control group comprised 33 randomly selected patients with intact stomachs. The primary end point of the study concerned the safety of PEG placement. The secondary end points included the efficacy and technical difficulty of the procedure. RESULTS: PEG/PEJ placement was successful in 14 of the 15 patients (93 %) who had previously had a subtotal gastrectomy. None of the study patients developed procedure-related complications. Feeding intolerance was more common in patients with gastrectomy compared with patients with an intact stomach, but the difference did not reach statistical significance (10 % vs. 3 %, P>0.05). A significantly higher incidence of pneumonia was observed in patients with gastrectomy compared with patients with an intact stomach (P=0.01). Subgroup analysis showed that the risk was higher with jejunal tube placement compared with gastric tube placement (42 % vs. 12 %, P=0.001). CONCLUSION: PEG/PEJ placement in patients with gastrectomy is a technically safe procedure. These patients are at higher risk of aspiration pneumonia and risk is higher with jejunal tube placement compared with gastric tube placement.     

Arteriographic evaluation of postsurgical stomach

Visceral arteriography was performed in 35 adult patients who had undergone various types of gastric surgery. Nineteen of these patients had presented with gastrointestinal hemorrhage at different postoperative intervals (4 days–23 years). Arteriography showed the bleeding site in 14 (74%) and permitted its nonoperative control in 8 cases. Diffuse hemorrhage from the gastric pouch as well as localized bleeding from suture line, marginal or stress ulcers, and other sources were recognized. Arteriography was also crucial in the diagnosis of iatrogenic arteriovenous fistulas, telangiectasia in the anastomotic regions, inadvertently ligated arteries, and postoperative changes in the vascular architecture. Value and limitations of arteriography of the postsurgical stomach are presented together with a review of the pertinent literature.     

Radiology of colonic interposition and its associated complications

A retrospective review of the medical records, pathology reports, and radiographic studies of 81 patients who had undergone colonic interposition was undertaken, with special attention to postoperative complications. Both early (within 30 days postoperatively, 81 patients) and late (later than 30 days postoperatively, 57 patients) complications were reviewed. Early findings included anastomotic narrowing (18 patients), anastomotic leak (13), aspiration (11), and ischemic necrosis of the colon (3). Late findings included aspiration (9 patients), anastomotic strictures (8), gastric stasis (6), redundancy and tortuosity of the colon (5), anastomotic ulcers (4), gastrocolic reflux (3), and gastroesophageal reflux into the residual esophagus (2).     

Salvage of a failed colon interposition in the esophagus with a free jejunal graft

A patient who had sustained lye burns of the esophagus had undergone reconstruction with a colon interposition. Because of necrosis and stricture of the interposed colon, he was unable to manage salivary secretions and was maintained on gastrostomy feedings. The defect from the pharynx to the midmanubrial level was reconstructed with a free jejunal graft by using microvascular surgical techniques. At 18-month follow-up, barium swallow roentgenography showed flow through the jejunal and colonic segments and into the stomach. The patient gained 15.9 kg postoperatively and was able to consume a normal diet.     

Laparoscopic surgery for sigmoid colon cancer after multiple operations including urinary diversion with Indiana pouch: A case report

A 73‐year‐old man with lower abdominal pain was diagnosed at our hospital with sigmoid colon cancer. He had previously undergone radical cystectomy with Indiana pouch construction and gastrectomy to treat bladder cancer and gastric cancer, respectively. We performed a laparoscopic Hartmann's operation with Japanese D3 lymph node dissection. We observed severe adhesion in the abdominal cavity; adhesions between the urostomy and sigmoid colon were particularly severe. The tumor had invaded to the distal rectum, which had adhered to the pubic bone and the previously reconstructed urinary pouch. By performing careful and persistent laparoscopic dissection, we completed the operation without damaging the urostomy and with no remnant tumor tissue (R0). The postoperative course was uneventful, and the patient was doing well with no evidence of cancer recurrence 1 year after surgery.     

Transjugular intrahepatic portosystemic shunt plus embolization for bleeding esophagojejunal varices after total gastrectomy

A 64-year-old man was admitted to our hospital with hematemesis and melena. Six years ago, he had undergone total gastrectomy with Roux-en-Y esophagojejunostomy for gastric cancer. Endoscopic examination revealed varicose veins at the anastomotic sites with cherry-red spots and hemorrhage. Abdominal computed tomography showed that the varices were supplied by a dilated jejunal vein. Transjugular intrahepatic portosystemic shunt (TIPS) and variceal embolization were performed. There were no major complications or episodes of bleeding during the three-month follow-up. We conclude that TIPS in combination with varices obliteration is an effective alternative method for treatment of ruptured esophagojejunal varices after total gastrectomy.     

Food residue at endoscopy in patients who have previously undergone distal gastrectomy: risk factors and patient preparation

BACKGROUND AND STUDY AIMS: Food residue is often seen in the gastric remnant after partial gastrectomy, making it difficult to diagnose early cancer in the residual stomach. The aims of this study were to clarify the risk factors for the accumulation of food residue, and to study methods of preparation for endoscopy in patients who had undergone distal gastrectomy. PATIENTS AND METHODS: 374 endoscopic examinations of patients who had undergone distal gastrectomy for gastric cancer were compared with 2168 endoscopic examinations in patients without a history of gastrectomy. Relationships between the presence of food residue and a number of clinical factors, including patient preparation, were evaluated by univariate and multivariate analyses. RESULTS: Food residue in the gastric remnant was observed in 70 examinations (18.7 %), a significantly higher proportion than that found in control patients (0.3 %). From multivariate analysis, underlying diseases (endocrine, metabolic, or connective tissue disease), Billroth type I reconstruction, and postoperative gastric retention were found to be independent risk factors for the accumulation of food residue. Diet preparation (a liquid diet plus aclatonium napadisilate) significantly decreased the incidence of food residue. CONCLUSIONS: Our diet preparation method can be recommended as a preparation for upper gastrointestinal endoscopy in patients who have undergone distal gastrectomy, especially in patients with additional risk factors.     

影响胃癌患者术后吻合口瘘的多因素分析

目的 探讨可能影响胃癌患者术后吻合口瘘发生的因素。方法 对2016年9月至2018年6月北京大学肿瘤医院行择期胃癌根治手术的499例患者病历资料回顾性研究。采用Logistic回归分析术后吻合口瘘的相关因素。结果 499例胃癌患者中,发生术后吻合口瘘23例(4.6%)。术后吻合口瘘相关因素有切除范围大(OR=2.633,P=0.045)、术中发生低血压(OR=4.617,P=0.007)、术后疼痛(OR=2.838,P=0.022)和饮酒史(OR=2.809, P=0.022)。结论 切除范围大、术中发生低血压、术后疼痛和饮酒史是术后吻合口瘘的危险因素。