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.     

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.     

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.     

A new method of jejunal reconstruction after pancreaticoduodenectomy

Although advances in pancreatic surgery have reduced mortality rates, post-operative morbidity remains a frequent problem in patients undergoing pancreaticoduodenectomy. The single most significant cause of morbidity in these patients is the development of pancreatic fistula. In this study, we assessed the occurrence of pancreatic fistula after isolated Roux loop pancreaticojejunostomy with the use of a haemostatic collagen-fibrin patch (TachoSil) to prevent pancreatic leakage. A total of 27 patients (15 men and 12 women, mean age 59 years, range 19-74 years) underwent proximal Whipple-type resection. Ten patients underwent a classical pancreaticoduodenectomy while a pylorus-preserving pancreaticoduodenectomy was performed in the other 17 patients. Reconstruction was done using three-jejunal anastomosis, with TachoSil applied at the end of the pancreatic jejunal anastomosis, along the entire anastomotic circumference. None of the 27 patients who underwent pancreaticoduodenectomy developed pancreatic fistula. One patient had bleeding from the gastro-jejunal anastomoses, five patients had infections of surgical sites, and three patients developed bacterial pneumonia. There were no significant differences in duration of surgery or intra-operative blood loss between patients with soft or hard pancreatic tissue. The reconstruction technique described here with three independent jejunal loops appears to offer good protection against pancreatic leakage.     

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.     

Gastric emptying following vagotomy and antrectomy and proximal gastric vagotomy.

Gastric emptying of solid meals labelled with 129Cs was studied in patients for up to one year after vagotomy and antrectomy or after proximal gastric vagotomy. Significant delay was found one month after vagotomy and antrectomy but this had returned to normal by six months. No delay was found after proximal gastric vagotomy. The effect of posture on gastric emptying was also studied in the same subjects. No significant differences were found between gastric emptying in the supine or sitting positions after solid meals.     

Erythromycin enhances gastric emptying in patients with gastroparesis after vagotomy and antrectomy

We studied the effect of erythromycin on gastric emptying in nine patients with gastroparesis following truncal vagotomy and antrectomy, and assessed their clinical response to chronic oral erythromycin. Gastric emptying was evaluated using a solid-phase radio-labeled meal. Patients were studied after erythromycin 200 mg intravenously (N=9) and after an oral suspension of erythromycin 200 mg (N=7) each given 15 min after ingestion of the meal. Three parameters of gastric emptying were analyzed: half-emptying time (T1/2), area under the curve, and percent gastric residual at 2 hr. Nine patients were subsequently placed on oral suspension erythromycin 150 mg three times a day before meals (range 125–250 mg three times a day) and symptoms of nausea, vomiting, postprandial fullness, and abdominal pain were assessed before and after erythromycin. Intravenous erythromycin markedly accelerated the gastric emptying (all three parameters studied) of solids (P<0.01) in seven of nine patients with postsurgical gastroparesis [baselineT1/2 154±15 min; after intravenous erythromycin,T1/2 56±17 min (mean ±sem)]. Oral erythromycin enhanced (P<0.05) the gastric emptying rate (T1/2, area under the curve) in five of seven patients (baselineT1/2 146±16 min; after oral erythromycin,T1/2 87±20 min). Of the nine patients who were placed on oral maintenance erythromycin, three showed clinical improvement after two weeks. In summary, erythromycin significantly enhances gastric emptying in many patients with vagotomy and antrectomy-induced gastroparesis; however, only a small subset of patients respond clinically to chronic oral erythromycin.Dr. Belinda Ramirez is in private practice in San Antonio, Texas.     

Diarrhea after total and selective vagotomy

The rate of evacuation of water from the stomach was found to be significantly increased by vagotomy and drainage procedure. The rate was not affected by the type of drainage procedure or vagotomy. The rate of emptying in patients who develop diarrhea after vagotomy and drainage procedure was significantly faster than that in patients who were symptom-free after operation.     

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.     

The type of anastomosis after selective gastric vagotomy and precise antrectomy is of no importance for basal and postprandial serum gastrin concentration

Twenty-six patients were treated for duodenal or recurrent ulcer with selective gastric vagotomy plus precise antrectomy--that is, complete removal of the entire antrum. Sixteen had a gastroduodenal anastomosis and 10 a gastrojejunal anastomosis. Fasting and protein meal-stimulated serum gastrin concentration was measured in 10 patients before antrectomy and in all after the operation. Fasting serum gastrin concentration was reduced and food-stimulated gastrin response abolished irrespective of the type of the anastomosis. It is concluded that a postprandial gastrin rise means retained antral tissue in the gastric remnant and that neither protein nor mechanical stimulation of the passage of food through the duodenum stimulates the duodenal G-cells to gastrin release.     

Gastric antrectomy with selective gastric vagotomy does not influence gallbladder motility during interdigestive and postprandial periods

Fasting gastrointestinal motility and gallbladder motility during the interdigestive state and in the postprandial period was studied in eight patients who were operated for ulcer disease with an antrectomy and selective gastric vagotomy. Nocturnal motility recording revealed all three phases of the migrating motor complex (MMC) in all but one patient, where no phase III activity was recorded. In the rest of the patients 3–10 events with phase III activity were recorded. At scintigraphy ([⁷⁵Se]HCAT) a cyclic gallbladder filling and emptying in relation to the MMC cycle was found. Episodes with emptying were confined to phase II and a total of 13 episodes with a median duration of 25 min (range 10–70 min) were observed. A median of 10.7% (6.1–17.7%) of the gallbladder contents was emptied. In a control group of eight healthy young men the values were 13.5 min (9–36 min) and 6.9% (3.7–31.1%), respectively. These differences were not significant. During the postprandial period, a lag period in gallbladder emptying of median 15 min (5–20 min) was observed when food ingestion took place during phase I of the MMC. Thereafter a gradual emptying occurred with a rate of 0.95%/min (0.71–1.15%/min). In a control group of healthy young males, the lag period was 13.5 min (9–22.5 min) and the emptying rate 0.61%/min (0.08–0.77%/min). When food ingestion occurred during phase II of the MMC, the lag period of gallbladder emptying in the patient group was median 0 min (0–5 min) and the emptying rate was 0.77%/min (0.33–0.86%/min). The values in the control group were 0 min (–9 to 13.5 min) and 0.76%/min (0.54–2.25%/min), respectively. These differences between the patients and controls were not significant. In conclusion, antrectomy and selective gastric vagotomy do not influence fasting gastrointestinal motility or gallbladder motility during the interdigestive state or in the postprandial period.     

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.     

Achalasia-like syndrome presenting after highly selective vagotomy

Summary Vagotomy is reported as a secondary cause of achalasia. Highly selective vagotomy, however, has rarely been reported to cause an achalasia-like syndrome. We suspect that periesophageal trauma accounted for the LES abnormalities seen at manometry in our patient but cannot explain the aperistalsis of the body of the esophagus. Pneumatic dilation improved his dysphagia only slightly but allowed him to maintain his nutrition with oral liquid enteral supplements. We recommend barium swallow, endoscopy, sounding the esophagus with a 50- to 60-French dilator, and manometry in evaluating patients with dysphagia after highly selective vagotomy. If an achalasia-like syndrome is demonstrated, then conservative management with observation and liquid nutritional supplements for four to eight weeks is appropriate. If this fails, pneumatic balloon dilation may be considered. Clearly, a preoperative history of dysphagia should prompt evaluation before highly selective vagotomy. This case represents a transient achalasia-like syndrome after highly selective vagotomy and signifies the importance of conservative management.The opinions expressed herein are solely those of the authors and do not reflect those of the U.S. Navy, the Department of Defense, or the U.S. Government.