Gastric tube reconstruction prevented esophageal reflux after proximal gastrectomy

Although the standard operation for early cancer of gastric cardia is proximal gastrectomy followed by jejunal interposition, we recently reported a simple and useful technique for proximal gastrectomy with gastric tube reconstruction. The operative procedures included resection of the proximal two-thirds of the stomach, followed by anastomosis between the esophagus and gastric tube, using a circular stapler (Proximate ILS 25; Ethicon, Cincinnati, OH, USA). The gastric tube was about 20 cm long and 4 cm wide. The patient a 76-year-old man had no reflux symptoms such as heartburn, retrosternal pain, and regurgitation. Endoscopy showed no evidence of reflux esophagitis, including mucosal redness, erosion, and ulceration. Ambulatory 24-h pH monitoring indicated that the pH of the lower esophagus was between 6 and 8 when the patient was upright and between 5 and 7 when he was in the supine position. There were nine reflux episodes during the day, and no reflux episode while he was asleep. The duration of each reflux episode was less than 1 min, and the total reflux time was 1 min in the 12-h day (0.1%). These data indicate that reconstruction by gastric tube may prevent esophageal reflux in patients who have undergone proximal gastrectomy for early cancer of the gastric cardia. Received for publication on Apr. 27, 1998; accepted on Aug. 19, 1998     

Surgical results of proximal gastrectomy for early-stage gastric cancer: jejunal interposition and gastric tube reconstruction

Background. The frequency of tumors in the upper one-third of the stomach has been increasing. The standard operation for proximal gastric cancer has been total or proximal gastrectomy. The aim of this study was to present the pathologic and surgical results of 30 patients with early-stage proximal gastric cancer managed by proximal gastrectomy. Methods. A consecutive series of 30 patients who underwent proximal gastrectomy for early-stage proximal gastric cancer was studied. Sixteen patients underwent jejunal interposition, while 14 underwent gastric tube reconstruction, which consisted of a direct anastomosis between the esophagus and the remnant of the tube-like stomach. Results. Twenty patients (67%) had no abdominal symptoms and the lesions were detected by screening gastric fiberscopy. The tumors were mostly located along the lesser curvature (73%), were grossly depressed type (IIc) (70%), and histologically well differentiated type (63%). The depth of wall invasion was the mucosa in 12 patients, submucosa in 15, and muscularis propria in 3; lymph node metastasis was absent in 28 patients (93%). When compared with patients with jejunal interposition, patients with gastric tube reconstruction had a shorter operation time (327 vs 165 min), less blood loss (508 vs 151 g), and shorter hospital stay after operation (31 vs 17 days). Endoscopy and 24-h pH monitoring showed no evidence of reflux esophagitis, except in 1 patient with gastric tube reconstruction, and no patient died of recurrence. Conclusions. Early-stage proximal gastric cancer can be successfully treated by proximal gastrectomy. Since gastric tube reconstruction is a simple, easy, and safe procedure, proximal gastrectomy followed by gastric tube reconstruction is recommended for patients with early-stage proximal gastric cancer. Received for publication on Jan. 5, 1999; accepted on Feb. 10, 1999     

Esophageal skip metastasis from an adenocarcinoma of the gastric cardia

Although diffuse‐type gastric carcinomas sometimes spread within the esophageal mucosa, a distant skip metastasis from a gastric carcinoma to the esophagus wall has rarely been reported. We herein report the case of a patient found to have a carcinoma of the gastric cardia with a skip metastasis to the esophagus, approximately 10 cm distant from the esophagogastric junction. A 53‐year‐old man was admitted to our department suffering from a sudden hematemesis. An upper gastrointestinal endoscopic study revealed an infiltrative ulcerating tumor of the gastric cardia and a small, reddish, elevated submucosal tumor on the middle third of the esophagus, apart from the tumor on the cardia. A histological study of the biopsy specimens from both tumors showed poorly differentiated adenocarcinomas. The patient underwent total thoracic esophagectomy and proximal gastrectomy combined with a splenectomy through a cervicoabdominal approach. The resected specimen contained a tumor of the cardia, 7.4 × 5.1 cm in area, that had infiltrated the submucosal layers of the lower esophagus up to 2.0 cm from the esophagogastric junction. The skip metastases were located 0.5, 4 and 7.2 cm from the oral side of the main tumor.     

重建贲门、胃底预防食管癌术后反流性食管炎的临床价值分析

目的 通过在管胃的基础上重建贲门(人工贲门)、胃底(人工胃底)探讨手术方式对预防食管癌术后胃食管反流的临床效果.方法 将73例食管癌患者按手术方式不同分成单纯管胃组(37例)和管胃+抗反流组(36例),分别在术后的1、6、12个月对患者术后的反流症状、上消化道造影、24 h pH值监测及胃镜结果 进行比较.结果 全组无手术死亡患者.术后反流症状、上消化道造影、胃镜等结果 提示管胃+抗反流组与管胃组组间比较差异无统计学意义(P>0.05).两组患者在24 h pH值测定术后1个月、6个月的总反流数,术后1个月、6个月的反流>5 min数,术后6个月、1年的pH值<4时间比较,差异有统计学意义(P<0.05),提示管胃+抗反流组抗反流效果总体优于单纯管胃组.其中管胃+抗反流组无吻合口瘘出现,但吻合口狭窄发生率要高于管胃组(19.4%vs 10.8%).结论 管胃+重建贲门、胃底术式较单纯管胃术式能更好地控制食管癌术后胃食管反流,且降低了术后出现吻合口瘘的风险.     

Clinicopathologic study of esophageal cancer associated with simultaneous metastatic lesions in the stomach

Between 1965 and 1985, 89 Japanese patients with esophageal squamous cell carcinoma underwent esophagectomy. In five of them (5.6%), a simultaneous metastatic lesion from the esophageal cancer was detected within the stomach in the resected specimens. Preoperative diagnosis of the gastric lesions had been made in none of the five patients because of an obstruction that was due to esophageal cancer. All gastric lesions were located at the gastric cardia, close to the esophagocardial junction, with a mean distance of 6.9 +/- 2.0 cm from the primary esophageal lesions. Provision of a gastric tube that contains metastatic lesions, for reconstruction of a new alimentary tract after esophagectomy, must be avoided. In cases of inadequate preoperative gastric examination, gastric lesions should be searched for intraoperatively, not only by serosal inspection and palpation, but also by mucosal inspection and palpation after partial proximal gastrectomy.     

Efficacy analysis of Cheng’s GIRAFFE reconstruction after proximal gastrectomy for adenocarcinoma of esophagogastric junction

ObjectiveReconstruction of the digestive tract for adenocarcinoma of esophagogastric junction (AEG) is in dispute. This study evaluated Cheng’s gastric tube interposition esophagogastrostomy with reconstruction of His angle and fundus (Cheng’s GIRAFFE anastomosis) in laparoscopic/open proximal gastrectomy for Siewert type II AEG, which was performed at Zhejiang Cancer Hospital and the First Affiliated Hospital of Zhejiang Chinese Medical University. Here, we discuss the preliminary results of gastric emptying and anti-reflux.MethodsFrom a retrospective database, 74 patients with advanced Siewert type II AEG underwent curative proximal gastrectomy with GIRAFFE anastomosis, and their gastric emptying and anti-reflux outcomes were evaluated by the Reflux Disease Questionnaire (RDQ) score, nuclide gastric emptying, 24-h impedance-pH monitoring and gastroscopy.ResultsSeventy-four patients successfully completed proximal partial gastrectomy with Cheng’s GIRAFFE esophagogastric anastomosis. RDQ score six months after the operation was 2.2±2.5. Results of nuclide gastric emptying examinations showed that the gastric half-emptying time was 67.0±21.5 min, the 1-h residual rate was (52.2±7.7)%, the 2-h residual rate was (36.4±5.1)%, and the 3-h residual rate was (28.8±3.6)%; 24-h impedance-pH monitoring revealed that the mean DeMeester score was 5.8±2.9. Reflux esophagitis was observed by gastroscopy in 7 patients six months after surgery.ConclusionsCheng’s GIRAFFE anastomosis is safe and feasible for Siewert type II AEG.     

Surgical treatment of concurrent cancer of the esophagus and stomach

Out of a total of 250 resections for carcinoma of the esophagus done in our department between 1965 and 1983, there were 11 patients with a concurrent esophageal cancer, nine being gastric cancer and seven of them early gastric cancer. In these nine, four underwent resection of the esophagus and lesser curvature of the stomach with gastric tube reconstruction. Two of the four patients are alive 10 and 3 yr postoperatively. We hold the view that detailed preoperative gastric examination is most important to plan the surgical repair and that the small gastric tube may serve as a substitute by resecting the lesser curvature of the stomach in cases of early proximal gastric cancer.     

Subtotal gastrectomy for gastric tube cancer after esophagectomy: a safe procedure preserving the proximal part of gastric tube based on intraoperative ICG blood flow evaluation

Recent improvements in the survival of patients after esophagectomy have led to an increase in the occurrence of gastric tube cancer (GTC). Total resection of the gastric tube with lymphadenectomy is a standard and reliable treatment for GTC, but problems may arise during or after surgery, such as laryngeal nerve injury, reduced selection of organs for reconstruction, and impaired swallowing function. We recently performed a less invasive procedure, subtotal gastrectomy with preservation of the upper region of the gastric tube, in two patients. In these patients, blood supply to the gastric tube was evaluated by indocyanine green fluorescence imaging. Blood flow was confirmed as passing from the remnant esophagus to the upper region of the gastric tube through the esophago-gastric anastomotic site by indocyanine green fluorescence imaging. Therefore, we resected the gastric tube while preserving the upper region of the gastric tube. There was no necrosis of the remnant gastric tube or anastomotic leakage postoperatively, and postoperative swallowing and eating functions were quite good in both patients. In summary, subtotal gastrectomy as a treatment for GTC is potentially safe, curative, and beneficial for the patient's quality of life.     

Fully robotic total gastrectomy with D2 lymphadenectomy for gastric cancer

PurposeRobotic surgery with technical advantages was shown to make complex maneuvers easier and more precise for gastric surgery [1]. This video demonstrates our technique on robotic total gastrectomy with the da Vinci Xi platform for gastric cancer.Methods68-year-old female was presented with persistent epigastric abdominal pain and underwent upper endoscopy showed ulcerated mass extended from the cardia to the lesser curvature. Histopathology showed gastric adenocarcinoma. After patient received neoadjuvant chemotherapy, decision was made to proceed with surgery.ResultsInitially, greater curvature dissection was started by division of the gastrocolic ligament with entering the lesser sac with monopolar scissors and bipolar forceps. The right gastroomental vessels were identified and divided at their root along with lymph nodes. After ligation of the right gastric vessels, dissection was extended to retrieve lymph nodes around the left gastric vessels. Duodenum was circumferentially dissected and transected 2 cm distal to the pylorus. Subsequently, extended lymphadenectomy was started with suprapancreatic lymph node dissection to retrieve lymph nodes around the common hepatic artery and celiac axis. Spleen-preserving dissection of the lymphatic tissue of the distal splenic artery and the splenic hilum was performed. The distal esophagus was divided with robotic stapler. Fully robotic end-to-side esophagojejunal anastomosis was constructed. For the reconstruction of gastrointestinal continuity after total gastrectomy, side-to-side jejuno-jejunal anastomosis was performed. Total operative time was 5 hours and estimated blood loss was 20 cc.DiscussionTotally robotic gastrectomy with D2-lymphadenectomy is a safe technique for gastric cancer and provides intracorporeal suturing in reconstructing the anatomy.     

全胃切除术与近端胃大部切除术治疗胃底贲门癌的远期疗效对比

目的 探讨不同术式治疗胃底贲门癌的远期疗效.方法 对58例胃底贲门癌患者采用手术治疗,其中全胃切除术29例,近端胃大部切除术29例.分析比较2组患者术后并发症和5年生存率.结果 全胃切除术和近端胃大部切除术患者3年生存率分别为62.07%和44.83%(P>0.05),5年生存率为48.28%和20.69%(P<0.05).近端大部切除组的反流性食管炎发生率为75.86%,高于全胃切除组的34.48%(P<0.05);2组患者的其他并发症发生率无统计学差异.肿瘤>3.0 cm和淋巴结转移患者全胃切除后5年生存率高于近端大部切除组(P<0.05),其他情况2组的生存率比较无差异.结论 对胃底贲门癌患者实施全胃切除术治疗能够有效提高患者的长期生存率,尤其是对于肿瘤>3.0 cm和出现淋巴结转移的患者.     

近端胃切除术后双通道吻合的研究进展

近年来,胃癌的总体发病率和死亡率在全世界都呈现上升趋势,其中近端胃癌（包括胃上部癌和食管胃结合部癌）发病率显著升高,严重威胁人类健康。全胃切除术和近端胃切除术是目前治疗近端胃癌的主要手术方式。近端胃切除术可缩小手术范围,且能最大程度保留胃的正常功能而逐渐受到关注,但该术式术后易发生反流性食管炎,影响患者生活质量。对于近端胃切除术后消化道重建方式的选择,如何保证患者术后的生活质量,降低术后胃食管反流症状的发生率是焦点。双通道消化道重建方式作为一种具有较好的抗返流效果的术式,受到国内外众多专家学者的认可。本文将回顾近年来关于近端胃切除术后双通道消化道重建术式的研究,并对未来的发展加以展望。     

Complications after proximal gastrectomy with jejunal pouch interposition: report of a case.

We report a rare case of proximal gastrectomy complication as a result of a severe dilatation of a jejunal pouch interposed for reconstruction. A 44-year-old man who had early gastric cancer underwent proximal gastrectomy with a jejunal pouch interposition at our department. Fourteen months after the procedure, he began to complain of left hypochondrial fullness and reflux symptoms. He had difficulty eating and his quality of life (QOL) was markedly impaired. Barium meal revealed severe dilatation of the jejunal pouch. Decompression using a stomach tube and other measures only achieved temporary improvement. 4.5 years later, the dilated jejunal pouch was resected together with apyloroplasty and double tract reconstruction. Six months after this secondary surgery, the patient recorded no further complications. Food intake increased and QOL improved.     

双S空肠间置术预防贲门癌切除术后反流性食管炎

目的：探讨消化道重建方式对贲门癌切除术后反流性食管炎的预防作用。方法：自１９９５年２月～１９９６年１０月采用双Ｓ空肠间置术行贲门癌切除术后消化消化道重建,并以传统的食管胃吻合和对照。将术后无病生存１年以上的７４例作为本文观察对象。其中双Ｓ组３８例,传统组３６例。结果：１）食 反流症状发生率：传统组７５％,双Ｓ组５．３％,两组间有非常显著性差异（Ｐ〈０．０１）。２）ｐＨ值测定：食管下段ｐＨ平均值传统     

全胃切除术治疗胃底贲门癌方法探讨

目的:探讨全胃切除治疗胃底贲门癌的合理性和消化道重建方式。方法:回顾分析1995年6月-2006年6月对98例病变较晚的胃底贲门癌患者行全胃切除术的临床资料。结果:单纯开腹手术48例,胸腹联合切口50例,全部采用食管-空肠Roux-y吻合,根治性切除86例,姑息性切除12例,术后出现吻合口瘘2例,肺部并发症2例,返流性食管炎3例,膈下脓肿1例,无吻合口狭窄、乳糜胸及死亡病例,并发症发生率为8.2%(8/98)。结论:全胃切除、食管-空肠Roux-y吻合术是治疗胃底贲门癌比较理想的重建术式,病变切除范围广,淋巴结清扫彻底,具有一定的代胃功能和较强的抗返流作用。     

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy

Background

No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years.

Methods

We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY.

Results

Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position.

Conclusions

SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

     

全胃切除、空肠翻转代胃消化道重建术的研究

目的探讨更加符合生理学要求的全胃切除消化道重建术式。方法对30例例胃癌患者行根治性全胃切除、翻转部分空肠代胃消化道重建术。结果30例患者术后未发生吻合口瘘及狭窄,无返流性食管炎、倾倒综合征和“无胃”综合征的发生。1年生存率为82．85（24／29）,2年生 率为65．5％（19／29）,3年生存率为52．6％（10／19）。82．8％（24／29）的患者术后6个月体重恢复或超过术前水平。结论根治性全胃切除,翻转部分肠代胃消化道重建术,是1种简捷易行,安全可靠的理想术式。     

Does the addition of Braun anastomosis to Billroth II reconstruction on laparoscopic-assisted distal gastrectomy benefit patients?

BACKGROUNDOperation is the primary therapeutic option for patients with distal gastrectomy. Braun anastomosis is usually performed after Billroth II reconstruction, which is wildly applied on distal gastrectomy because it is believed to benefit patients. However, studies are needed to confirm that.AIMTo identify whether the addition of Braun anastomosis to Billroth II reconstruction on laparoscopy-assisted distal gastrectomy benefits patients.METHODSA total of 143 patients with gastric cancer underwent laparoscopy-assisted distal gastrectomy at Centre 1 of PLA general hospital between January 2015 and December 2019. Clinical data of the patients were collected, and 93 of the 143 patients were followed up. These 93 patients were divided into two groups: Group 1 (Billroth II reconstruction, 33 patients); and Group 2 (Billroth II reconstruction combined with Braun anastomosis, 60 patients). Postoperative complication follow-up data and relevant clinical data were compared between the two groups.RESULTSThere were no significant differences between Group 1 and Group 2 in postoperative complications (6.1% vs 6.7%, P = 0.679), anal exhaust time or blood loss. The follow-up prevalence of reflux gastritis indicated no significant difference between Group 1 and Group 2 (68.2% vs 51.7%, P = 0.109). The follow-up European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 scores revealed no evident difference between Group 1 and Group 2 as well. Group 1 had a shorter operating time than Group 2 on average (234.6 min vs 262.0 min, P = 0.017).CONCLUSIONCombined with Billroth II reconstruction, Braun anastomosis has been applied due to its ability to reduce the prevalence of reflux gastritis. Whereas in this study, the prevalence of reflux gastritis showed no significant difference, leading to a conclusion that under the circumstance of Braun anastomosis costing more time and more money, simple Billroth II reconstruction should be widely applied.     

腹腔镜近端胃癌根治术消化道重建的历史与现状

世界范围内的近端胃癌发生率逐年升高，根治性胃切除仍是其治疗的主要方法。随着腹腔镜微创技术的发展，保留部分胃功能的腹腔镜下近端胃切除近年来备受关注。因肿瘤位置的特殊性，消化道重建方式的选择仍存在争议，本文对目前的腹腔镜近端胃癌根治术后消化道重建方式进行综述，为临床医师合理选择消化道重建方式提供参考。     

R-Y吻合在远端胃癌根治术中的应用

目的:探讨R-Y吻合在远端胃癌根治术中的优势。方法:回顾性分析并总结我院近3年56例远端胃癌根治术患者临床资料，B-Ⅱ吻合术组26例，R-Y吻合术组30例。比较两组患者术后并发症及营养状态。结果:R-Y组手术时间略长于B-Ⅱ组（P＜0.05）；R-Y组反流性食管炎发生率低于B-Ⅱ组（P＜0.05），其余并发症差异无统计学意义(P＞0.05)；两组住院天数相似无差异（P＞0.05）；两组患者术后1年BMI变化、白蛋白变化、淋巴细胞计数变化差异无统计学意义(P＞0.05)。结论:R-Y术式在远端胃癌根治术消化道重建中是安全可靠的，反流性食管炎发生率降低，改善了患者术后生活质量，应作为远端胃癌根治术的首选吻合方式。     

早期胃癌ESD治疗后腹腔镜补救手术3例并文献复习

目的 探讨早期胃癌患者行内镜黏膜下剥离术(ESD)后未达治愈标准的补救方式的选择及行腹腔镜补救手术的安全性和可行性.方法 收集3例早期胃癌ESD治疗后未达治愈标准再行腹腔镜补救手术患者的病例资料,分析其临床病理特征及补救手术指征,并对手术效果进行评价.结果 3例行腹腔镜补救根治性手术的早期胃癌患者ESD治疗均整块切除,术后病理示3例患者的病变黏膜下浸润均超过500μm,其中垂直切缘阳性患者1例,有静脉浸润患者1例,病变直径大于3 cm的患者2例;3例患者行腹腔镜补救手术均无中转开腹,术后均未发现有癌残留及淋巴结转移;手术时间111~151 min,术中出血量50~100 ml,无术中输血.术后排气时间为3~5 d,拔除胃管时间为4~6 d,拔除引流管时间为6~7 d,术后住院天数为8~13 d;3例患者均无手术相关并发症.结论 腹腔镜补救根治性手术是非治愈性ESD后一种安全有效的补救方式.