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.     

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.     

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.     

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.     

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.     

Use of a jejunal pouch with ileal interposition in salvage surgery after restorative proctocolectomy

PURPOSE: A novel technique is described for pouch reconstruction after failed restorative proctocolectomy and pouch excision. METHODS: Surgery was undertaken in two patients who had undergone restorative proctocolectomy with subsequent excision of the ileal J-pouch after necrosis. At revisional surgery it was technically impossible to form a pouch using the terminal ileum because of mesenteric shortening. A new 18-cm J-pouch was formed with a jejunal segment. After selective division of axial vessels, adequate length was obtained to allow formation of a jejunal-pouchanal anastomosis. The small bowel distal to the pouch was interposed between the proximal jejunum and J-pouch and a defunctioning stoma was made. RESULTS: The postoperative course was uneventful in both cases. The functional results at 3 and 12 months after stoma closure were good, with five to seven bowel movements per day and complete continence. CONCLUSION: Shortening of the terminal ileal mesentery may preclude the formation of an ileal pouch in patients undergoing salvage surgery after failed restorative proctocolectomy. This novel technique of jejunal J-pouch formation and small-bowel interposition has value as an alternative to definitive ileostomy or Kock's pouch in such patients.     

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.     

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.     

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.     

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.     

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.     

Clinical outcome of jejunal pouch double-tract reconstruction after total gastrectomy

BACKGROUND/AIMS: The importance of the duodenal passage and the need for pouch reconstruction after total gastrectomy are matters of controversy. METHODOLOGY: Twenty consecutive patients with early gastric cancer were studied 20who underwent jejunal pouch double-tract (JPD) reconstruction after total gastrectomy. Nutritional variables were examined for > or =10 years postoperatively. RESULTS: The mean operation time was 204 minutes. There was no anastomotic leakage and no hospital mortality. Anastomotic stenosis between the esophagus and a jejunal pouch developed in 2 patients (10%), and reflux esophagitis was observed in 4 (20%). Symptoms were controlled by conserva tive treatment within 3 years after surgery. Body mass indices in all patients were significantly decreased from 1 month (p<0.05) to 10 years (p<0.005) after the operation. The mean body weight decrease occurring during the first to the tenth postoperative year was 12.7% overall, but 17.8% and 9.1% in patients aged > or =60 years and <60 years, respectively. The body weight decreases from 3 (p<0.05) to 6 (p<0.01), and at 9 years (p<0.01) were significantly lower before 60 years of age than after. CONCLUSIONS: JPD reconstruction facilitates long-term recovery of body weight after total gastrectomy and should be considered before the aged of 60.     

Long-term results after surgery for gastric cancer with or without jejunal reservoir: results of surgery for gastric cancer in Kanta-Häme central hospital in two consecutive periods without or with jejunal pouch reconstruction in 1985-1998

Background: Gastric cancer still has a disease-specific 5-yr survival less than 30% and an overall survival of about 15%. The quality of life of patients who undergo gastrectomy is poor owing both to the severity of the disease itself and to the mutilation of the upper gastrointestinal channel after the reconstruction. Therefore, the combination of a jejunal pouch with gastrectomy has been claimed to improve the life quality and nutritional status of these patients. Aim: To assess the clinical results after surgery for gastric cancer in two consecutive periods with or without jejunal-pouch reconstruction. Methods: 271 consecutive patients referred for surgery for gastric cancer in 1985–1991 (116 patients) and in 1992–1998 (155 patients) in Kanta-H?me central hospital were retrospectively analyzed regarding their disease, mode of surgery, and the immediate and long-term results. In the former observation period gastrectomy was performed with Roux-en-Y esophagojejunostomy without a reservoir, and in the latter period this procedure was combined with a jejunal reservoir. The data were collected from patient journals and from the death certificate obtained from the National Centre of Statistics in Finland. Results: During the study period the incidence of cancer in the cardia increased among the surgical patients from 13.1 to 26.7% (p <0.05). Despite this proximal migration, the cancer-specific 5-yr survival remained practically unchanged during the two study periods, 29.4% and 32.2% (NS). During the period of jejunal-pouch reconstruction there were non-significant increases of the incidences of local recurrence (from 18.9% to 26.5%), of immediate postoperative anastomotic fistulae (from 0.9% to 4.5%) as well as of the immediate mortality (from 2.6% to 3.7%) (NS for each). Conclusions: Despite proximal migration of gastric cancer and the application of a jejunal reservoir, the long-term as well as the immediate results after curative surgery (i.e., D2-gastrectomy) for gastric cancer have remained relatively unchanged. The jejunal-pouch reconstruction with the present technique after gastrectomy can therefore be safely applied.     

Pouch stomach reconstruction after gastrectomy]

Up to now there is no general agreement on the ideal reconstruction after total gastrectomy. The importance of the duodenal passage, the need for a pouch reconstruction, and the ideal pouch volume are matters of controversy. Prospective randomized trials show a significantly better quality of life, a higher body weight and a better glucose regulation in patients with a curative operation and good life expectancy, if the duodenal passage is preserved. Reconstruction with a small jejunal pouch offers a better reservoir, less reflux and a better nutritional passage, but a statistically significant improvement of life quality could not be demonstrated up to now. Nevertheless, patients with a curative resection should undergo pouch reconstruction with preservation of the duodenal passage. If curative resection is not possible, reconstruction can be performed according to Hunt-Lawrence-Rodino. The Roux-en-Y-reconstruction without pouch should only be performed in high-risk patients and in carcinoma of the cardia with intrathoracic anastomosis. Nevertheless, further prospective randomized studies with more patients and more specific tests to measure life quality are necessary to evaluate the importance of a jejunal pouch in patients with a preserved duodenal passage.     

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.     

Long term consequences of gastrectomy for patient's quality of life: the impact of reconstructive techniques

OBJECTIVE: During recent years considerable interest has been focused on quality of life as an additional therapeutic outcome measure in the surgical treatment of gastric carcinoma. However, the long term consequences of gastrectomy and the impact on quality of life of different reconstructive techniques are still a matter of controversy. To broaden the criteria for choice of treatment, we conducted a prospective randomized clinical trial to determine the impact of various gastrectomy procedures on quality of life during a 5-yr follow-up period. METHODS: Consecutive patients (n = 64) eligible for curative gastric cancer surgery were randomized to have either total (n = 31) or subtotal (n = 13) gastrectomy or a jejunal S-shaped pouch (n = 20) as a gastric substitute after total gastrectomy. Assessments of quality of life were made on seven occasions during a 5-yr period: within 1 wk before surgery, 3 and 12 months after the surgical intervention, and then once/yr. All patients were interviewed by one of two psychiatrists, who rated their symptoms and introduced standardized self-report questionnaires covering both general and specific aspects of life. The raters were blinded for the patients' group affiliations. RESULTS: Survival rates were similar in all treatment groups. Patients who had a total gastrectomy continued to suffer from alimentary symptoms, especially indigestion and diarrhea, during the entire follow-up period. However, patients who underwent subtotal gastrectomy had a significantly better outcome already during the first postoperative yr. Patients given a gastric substitute after gastrectomy improved with the passage of time and had an even better outcome in the long run. CONCLUSIONS: To optimize the rehabilitation after gastrectomy, patients' quality of life must be taken into consideration. When subtotal gastrectomy is clinically feasible, this procedure has advantages in the early postoperative period. However, a pouch reconstruction after total gastrectomy should be considered in patients having a favorable tumor status suggesting a fair chance of long term survival.     

Results of follow-up endoscopy in patients who underwent proximal gastrectomy with jejunal interposition for gastric cancer

BACKGROUND/AIMS: The present study evaluates the findings of long-term follow-up endoscopy in patients who underwent proximal gastrectomy with jejunal interposition for gastric cancer. METHODOLOGY: A total of 55 patients (45 males, 10 females; 32 to 79 years; mean, 55.9 years), who underwent proximal gastrectomy with jejunal interposition, were enrolled in the present study. We reviewed the findings of follow-up endoscopy of all patients with particular reference to the development of esophagitis, jejunitis, jejunal ulcer and secondary tumors. RESULTS: We found reflux esophagitis in 6 patients (10.9%) between 12 and 35 months with an average of 22 months after surgery. Jejunitis was discovered in 5 patients (9.0%) between 6 and 96 months with an average of 29 months after surgery. Jejunal ulcer was revealed in 6 patients (10.9%) between 6 and 75 months with an average of 37 months after surgery. Tumors of the remnant stomach, early gastric cancer and gastric adenoma, were identified in 2 patients (3.6%) at 24 months and 69 months, respectively. CONCLUSIONS: Jejunal interposition combined with proximal gastrectomy does not always prevent complications related to regurgitation of gastric content, and may not be a suitable treatment in view of postoperative endoscopic surveillance. Further studies are required to identify an appropriate surgical approach to proximal gastrectomy for gastric cancer.     

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 &lt; 0.05) and early satiety (86% compared with 5%, P &lt; 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 &lt; 0.05), and the patients ate fewer meals per day (mean, 2.7 versus 5.3, P &lt; 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 &lt; 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 mean163 U/l to 248 U/l, P &lt; 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.     

Human gastric and jejunal transit and motility after Roux gastrojejunostomy.

Upper gut transit and motility among 10 symptomatic and 9 asymptomatic patients with Roux gastrectomy were compared with those among 10 healthy, unoperated controls. Gastric emptying of solids and Roux limb and small intestinal transit of liquids were assessed scintigraphically. Motor patterns in the Roux limb or healthy jejunum were recorded manometrically. Whereas gastric emptying was sometimes faster and sometimes unchanged after Roux gastrectomy compared with controls, Roux limb transit in patients was consistently slower than jejunal transit in controls. Postprandially, the Roux limb showed decreased overall motility, fewer clustered waves, and less aboral migration of clustered waves than the healthy jejunum. Symptomatic Roux patients had jejunal transit and motor patterns similar to those of asymptomatic patients. Nonetheless, reflux from Roux limb to gastric remnant occurred in 4 of 10 symptomatic patients but in none of the asymptomatic patients. In conclusion, stasis and dysmotility are present in the Roux limb after Roux gastrectomy and Roux-gastric reflux can occur. Other factors, however, must have a role in determining whether symptoms appear.     

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.