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.     

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 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.     

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.     

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.     

An experimental study on the gastric acid and gut hormone secretion after pylorus preserving duodenectomy in dogs.

To clarify changes in gastric acid and gut hormone secretion after pylorus-preserving pancreaticoduodenectomy (PPPD), an experimental study was performed using a model of pylorus-preserving duodenectomy in dogs previously provided with Heidenhain pouch (HP). The duodenectomy involves resection of the duodenum and 10 cm of the proximal jejunum preserving 2 cm of juxtapyloric duodenum and round-shaped duodenal wall around pancreatic papilla. Reconstruction was done by anastomosing the rho-shaped jejunal loop to gallbladder, juxtapyloric duodenum and peripapillar round-shaped duodenal wall with ligation of the common bile duct. For these dogs, intravenous glucose tolerance test (IVGTT), oral glucose tolerance test (OGTT), meal ingestion test (TM) and histological studies of pancreatic specimen obtained at autopsy were performed investigating pancreatic, gastric acid and gut hormone secretion. Preservation of endocrine and exocrine pancreatic secretion after operation demonstrated our experimental model to be adequate for evaluation of the factor of duodenectomy in PPPD on gastric acid and gut hormone secretion avoiding the influences of changes in pancreatic secretion. Postprandial gastric acid secretion from HP did not change significantly after operation. Postprandial secretion of gastrin, glucagon, GIP and enteroglucagon did not alter significantly after operation. These results indicated that in the clinical PPPD procedure, preservation of more than 2 cm of duodenum from the pylorus produced neither postprandial gastric acid hypersecretion, which might be cause of postoperative stomal ulcer, nor any change of related gut hormone secretion.     

Pancreaticojejunostomy,hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases

Surgery such as digestive tract reconstruction is usually required for pancreatic trauma and severe pancreatitis as well as malignant pancreatic lesions. The most common digestive tract reconstruction techniques (e.g., Child’s type reconstruction) for neoplastic diseases of the pancreatic head often encompass pancreaticojejunostomy, choledochojejunostomy and then gastrojejunostomy with pancreaticoduodenectomy, whereas these techniques may not be applicable in benign pancreatic diseases due to an integrated stomach and duodenum in these patients. In benign pancreatic diseases, the aforementioned reconstruction will not only increase the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the risks of traction, twisting and angularity of the jejunal loop. In addition, postoperative complications such as mixed fistula are refractory and life-threatening after common reconstruction procedures. We here introduce a novel pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction in two cases of benign pancreatic disease, thus decreasing not only the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the possibility of postoperative complications compared to common reconstruction methods. Postoperatively, the recovery of these patients was uneventful and complications such as bile leakage, pancreatic leakage and digestive tract obstruction were not observed during the follow-up period.     

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.     

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.     

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.     

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.     

Comparison of free jejunal graft with gastric pull-up reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma

SUMMARY.  The purpose of this study is to evaluate the operative outcomes of a gastric pull-up and free jejunal graft reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma. Records of all patients who underwent esophageal resection for carcinoma of the hypopharynx and cervical esophagus were reviewed. Reconstruction after esophagectomy was performed using the gastric pull-up ( n  = 38) or free jejunal graft ( n  = 14) techniques. The hypopharynx was the most common primary tumor site for the free jejunal graft group, whereas the gastric pull-up group had lesions more frequently in the cervical esophagus ( P  < 0.05). Both operative time and blood loss in the gastric pull-up group were significantly longer and excessive than those of the free jejunal graft group ( P  < 0.05). The graft survival rate was 95% (32/34) in the gastric pull-up group and 93% (13/14) for the free jejunal transfer group. The overall leakage rate was 1.9% (1/52). Three patients died (6%) in the postoperative period. There was no significant difference with regard to operative morbidity and mortality between the gastric pull-up group and free jejunal graft group. In conclusion, both free jejunal graft and gastric pull-up are safe and effective methods for the immediate restoration of alimentary continuity.     

Marginal ulceration after pylorus-preserving pancreaticoduodenectomy

Marginal ulceration is a serious problem after both standard pancreaticoduodenectomy (PD) and pylorus‐preserving pancreaticoduodenectomy (PPPD). The relationship between this complication and the method of reconstruction after PPPD was analyzed in this study. Patients who underwent standard PD (n = 72) or PPPD (n = 28) in the 20‐year period from 1978 to 1997 were retrospectively reviewed. After PPPD, 4 patients (14.3%) developed marginal ulceration on the jejunal side of the duodenojejunal anastomosis, while none of the patients had marginal ulceration after standard PD. The marginal ulcer occurred in 3 of 14 patients treated with the Roux‐en‐Y method, and in 1 of 9 treated with pancreatogastrostomy. In the Roux‐en‐Y method, the anal jejunal loop anastomosed to the bulb was directly exposed to gastric juice without neutralization by pancreatic juice from the oral jejunal limb. Of the 4 patients with marginal ulceration, 2 of those treated by the Roux‐en‐Y method required gastrectomy; the other 2 patients were treated medically. Our analysis of the literature showed that the Roux‐en‐Y method had the highest incidence of marginal ulcerations. The gastrointestinal reconstruction method without a mixture of gastric juice and pancreatic juice may be a causal factor in the marginal ulceration that occurs after PPPD. In reconstruction after PPPD, we should not create a jejunal loop that is exposed to gastric juice alone.     

A rare source of occult gastrointestinal bleeding: jejunal filiae secondary to metastatic lung carcinoma

A case of occult gastrointestinal bleeding due to jejunal metastases of a primary lung carcinoma in a 53-year-old man is reported. When after healing of a large gastric ulcer melena persisted, a subsequently performed double contrast enema of the small bowel revealed evidence of several jejunal tumors. This was confirmed by angiography of the superior mesenteric artery and computed tomography of the abdomen. After resection of the tumor-bearing jejunal loop, histological evaluation revealed metastases secondary to a large-cell bronchogenic carcinoma which had been resected 1 year previously.     

The use of endoscopy after gastric partitioning for morbid obesity

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.     

Pancreaticoduodenectomy following total gastrectomy:A case report and literature review

We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG.The patient was a69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years.The patient underwent PD for pancreas head adenocarcinoma.A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy.Despite normal patency of the hepaticojejunostomy,he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb(15 cm in length).We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion.The refractory cholangitis resolved immediately after the receliotomy and did not recur.Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG.This issue warrants further attention,particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.     

Laparoscopic subtotal gastrectomy for gastric carcinoma treatment

Laparoscopic surgery of the stomach is not well accepted in patients with malignant disease. This paper shows the first experiences with this procedure at the Clinical Hospital and Medical School, Split, in two patients with early stage gastric carcinoma. The first patient was a 57 year old man who had had some gastric symptoms for a while. The other patient was a 73 year old man who had ulcer disease 52 years ago. Laparoscopic subtotal gastrectomy with omentectomy and Roux-en-Y reconstruction of the alimentary tract was performed on both patients. Pathohystological analysis of the resected part of the stomach showed the early stage gastric adenocarcinoma without metastases to the lymph nodes around the stomach or any pathological changes in the omentum for both of the patients. There were no complications during postoperative period. The first patient was released from the hospital after 8 and other after 9 days. All oncological principles were satisfied with laparoscopic subtotal resection with good and fast postoperative recovery without complications.     

胃癌病人全胃切除、代胃及人工幽门括约肌重建术的远期疗效观察

目的 观察胃癌病人行全胃切除、代胃及人工幽门括约肌重建术的远期疗效。方法 连续5年对应用此法治疗的106例胃癌患者的营养状况、生存率、术后并发症发生率以及术后生活质量等情况进行定期随访。结果 本组患者5年生存率42．5％，碱性反流性食管炎的发生率为0．9％，术后5年胆石症发生率为5．66％，生活质量优良率为89．6％。结论 全胃切除、代胃及人工幽门括约肌重建术治疗进展期胃癌有较好的远期疗效。