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Kubota A, Yamauchi S, Yoshimoto Y, Tsuda K, Yube Y, Kaji S, Orita H, Brock MV, Fukunaga T. Impact of the Aboral Pouch in Roux-en-Y Reconstruction after Laparoscopic Total Gastrectomy for Elderly Patients. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2024; 70:204-213. [PMID: 39429689 PMCID: PMC11487364 DOI: 10.14789/jmj.jmj23-0036-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/18/2024] [Indexed: 10/22/2024]
Abstract
Objectives The number of elderly people with stomach cancer is increasing; therefore, minimally invasive surgical treatments are required. Elderly patients have multiple comorbidities and are prone to postoperative weight loss, nutritional disorders, Postgastrectomy syndrome (PGS), and decreased quality of life (QOL). Total gastrectomy is particularly associated with these complications, although aboral-pouch creation reportedly improves the condition by compensating for lost reservoir capacity. However, there is no consensus regarding its significance. This study aimed to investigate the impact of the aboral pouch on total gastrectomy outcomes in elderly patients. Materials and Methods Thirty-six patients who met the eligibility criteria, defined as elderly patients aged ≥75 years, were retrospectively analyzed. The patients had undergone Roux-en-Y reconstructions with an aboral pouch in laparoscopic total gastrectomy procedures performed at Juntendo University from July 2016 to June 2022. The main outcomes were postoperative nutritional status, PGS, and QOL. Results The average postoperative period was approximately 1 year (12.0 vs. 13.5 months, P=0.536), for 14 elderly and 22 non-elderly patients, respectively. Elderly patients had more comorbidities (78.5% vs. 40.9%, P=0.041). The outcome of nutritional status demonstrated no differences in weight-loss rate (-5.3% vs. -8.6%, P=0.651) or prognostic nutritional status (-7.9% vs. -5.9%, P=0.243). There was no significant difference in PGS and QOL between elderly and non-elderly patients. Conclusions Total gastrectomy with an aboral-pouch creation could be beneficial for elderly 43 patients from the perspective of postoperative nutritional status, PGS, and QOL.
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Realis Luc M, Bonomi AM, Carbone F, Ascari F, de Pascale S, Fumagalli Romario U. Roux-en-Y with or without jejunal J-pouch reconstruction after total gastrectomy for gastric cancer: systematic review and meta-analysis of long-term functional outcomes. J Gastrointest Surg 2024; 28:291-300. [PMID: 38445924 DOI: 10.1016/j.gassur.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Increased survival of patients undergoing total gastrectomy for gastric cancer has prompted several efforts to improve long-term postgastrectomy syndrome (PGS) outcomes. Whether a J-pouch (JP) reconstruction may be more beneficial than a standard Roux-en-Y (RY) is controversial. METHODS A systematic review with meta-analysis was conducted, including studies reporting long-term outcomes of patients treated with total gastrectomy and JP vs RY esophagojejunostomy for gastric adenocarcinoma. A literature search was performed on PubMed, Scopus, and Google Scholar. Primary endpoints were symptom control, weight loss, eating capacity (EC), and quality of life (QoL) with at least 6 months of follow-up. Safety endpoints were explored. RESULTS Overall, 892 patients were included from 15 studies (6 randomized controlled trials [RCTs] and 9 non-RCTs): 452 (50.7%) in the JP group and 440 (49.3%) in the RY group. Compared with RY, JP showed a significantly lower rate of dumping syndrome (13.8% vs 26.9%, odds ratio [OR], 0.29; 95% confidence interval [CI], 0.14-0.58; P < .001; I2 = 22%) and heartburn symptoms (20.4% vs 39.0%; OR, 0.29; 95% CI, 0.14-0.64; P = .002; I2 = 0%). Reflux (OR, 0.61; 95% CI, 0.28-1.32; P = .21; I2 = 42%) and epigastric fullness (OR, 0.60; 95% CI, 0.18-2.05; P = .41; I2 = 69%) were similar in both groups. Weight loss and EC were similar between the groups. QoL outcome seemed to be burdened by bias. There was no difference in morbidity, mortality, and anastomotic leak rate between groups. Operative time was significantly longer for JP than for RY (271.9 vs 251.6 minutes, respectively; mean difference, 21.55; 95% CI, 4.64-38.47; P = .01; I2 = 96%). CONCLUSION JP reconstruction after total gastrectomy for gastric cancer is as safe as RY and may provide an advantage in postgastrectomy dumping syndrome and heartburn symptoms.
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Affiliation(s)
- Marco Realis Luc
- Digestive Surgery, European Institute of Oncology IRCCS, Milan, Italy; University of Milan, Milan, Italy
| | - Alessandro Michele Bonomi
- Digestive Surgery, European Institute of Oncology IRCCS, Milan, Italy; University of Milan, Milan, Italy
| | - Fabio Carbone
- Digestive Surgery, European Institute of Oncology IRCCS, Milan, Italy.
| | - Filippo Ascari
- Digestive Surgery, European Institute of Oncology IRCCS, Milan, Italy
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Tsuji T, Isobe T, Seto Y, Tanaka C, Kojima K, Motoori M, Ikeda M, Nitta T, Oshio A, Nakada K. Effects of creating a jejunal pouch on postoperative quality of life after total gastrectomy: A cross-sectional study. Ann Gastroenterol Surg 2022; 6:63-74. [PMID: 35106416 PMCID: PMC8786703 DOI: 10.1002/ags3.12497] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/29/2021] [Accepted: 08/15/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Total gastrectomy results in the complete loss of gastric function and the development of severe postgastrectomy syndrome. During the jejunal pouch procedure following total gastrectomies, a substitute stomach is created to alleviate the effects of postgastrectomy syndrome. However, the procedure's effectiveness remains controversial. This study aimed to explore the effect of jejunal pouch creation after total gastrectomy on postoperative quality of life. METHODS A nationwide multi-institutional cross-sectional study, the Postgastrectomy Syndrome Assessment study NEXT, used the Postgastrectomy Syndrome Assessment Scale-45 questionnaire to explore the optimal gastrectomy procedure for cancer located in the upper third of the stomach or around the esophagogastric junction. The questionnaire consists of 45 items consolidated into 19 main outcome measures relating to postgastrectomy symptoms, amount of food ingested, quality of ingestion, ability for working, level of satisfaction for daily life, and the physical and mental component summary of the 8-Item Short Form Health Survey. Eligible completed questionnaires were retrieved from 1909 patients. Of these, the data were analyzed for 1020 patients who underwent total gastrectomy and 93 patients who underwent jejunal pouch creation after total gastrectomy. RESULTS Postoperative quality of life was compared between patients with and without pouches. The analysis revealed that patients with pouches, particularly oral pouches, experienced substantially improved postoperative quality of life than those without, even after adjusting for several clinical factors using multiple regression analyses. CONCLUSION The results suggest that total gastrectomy with jejunal pouch creation, particularly oral pouches, may significantly improve postoperative quality of life.
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Affiliation(s)
- Toshikatsu Tsuji
- Department of Gastroenterological SurgeryIshikawa Prefectural Central HospitalIshikawaJapan
| | - Taro Isobe
- Department of SurgeryKurume University School of MedicineKurumeJapan
| | - Yasuyuki Seto
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - Chie Tanaka
- Department of Gastroenterological SurgeryNagoya University Graduate School of MedicineNagoyaJapan
| | - Kazuyuki Kojima
- First Department of SurgeryDokkyo Medical University HospitalTochigiJapan
| | | | | | - Toshikatsu Nitta
- Division of SurgeryGastroenterological CenterMedico Shunjyu Shiroyama HospitalOsakaJapan
| | - Atsushi Oshio
- Faculty of Letters, Arts and SciencesWasedaTokyoJapan
| | - Koji Nakada
- Department of Laboratory MedicineThe Jikei University School of MedicineTokyoJapan
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Lu S, Ma F, Zhang Z, Peng L, Yang W, Chai J, Liu C, Ge F, Ji S, Luo S, Chen X, Hua Y. Various Kinds of Functional Digestive Tract Reconstruction Methods After Proximal Gastrectomy. Front Oncol 2021; 11:685717. [PMID: 34414108 PMCID: PMC8369505 DOI: 10.3389/fonc.2021.685717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023] Open
Abstract
The incidence of proximal gastric cancer has shown a rising trend in recent years. Surgery is still the main way to cure proximal gastric cancer. Total gastrectomy with D2 lymph node dissection was considered to be the standard procedure for proximal gastric cancer in the past several decades. However, in recent years, many studies have confirmed that proximal gastrectomy can preserve part of the stomach function and can result in a better quality of life of the patient than total gastrectomy. Therefore, proximal gastrectomy is increasingly used in patients with proximal gastric cancer. Unfortunately, there are some concerns after proximal gastrectomy with traditional esophagogastrostomy. For example, the incidence of reflux esophagitis in patients who underwent proximal gastrectomy with traditional esophagogastrostomy is significantly higher than those patients who underwent total gastrectomy. To solve those problems, various functional digestive tract reconstruction methods after proximal gastrectomy have been proposed gradually. In order to provide some help for clinical treatment, in this article, we reviewed relevant literature and new clinical developments to compare various kinds of functional digestive tract reconstruction methods after proximal gastrectomy mainly from perioperative outcomes, postoperative quality of life and survival outcomes aspects. After comparison and discussion, we drew the conclusion that various functional reconstruction methods have their own advantages and disadvantages; large scale high-level clinical studies are needed to choose an ideal reconstruction method in the future. Besides, in clinical practice, surgeons should consider the condition of the patient for individualized selection of the most appropriate reconstruction method.
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Affiliation(s)
- Shuaibing Lu
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei Ma
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhandong Zhang
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Liangqun Peng
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Yang
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Junhui Chai
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Chen Liu
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Fusheng Ge
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Sheqing Ji
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Suxia Luo
- Department of Medical Oncology, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaobing Chen
- Department of Medical Oncology, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Yawei Hua
- Department of General Surgery, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
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Kosuga T, Tsujiura M, Nakashima S, Masuyama M, Otsuji E. Current status of function-preserving gastrectomy for gastric cancer. Ann Gastroenterol Surg 2021; 5:278-286. [PMID: 34095717 PMCID: PMC8164463 DOI: 10.1002/ags3.12430] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 12/17/2022] Open
Abstract
Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.
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Affiliation(s)
- Toshiyuki Kosuga
- Department of SurgerySaiseikai Shiga HospitalRittoJapan
- Division of Digestive SurgeryDepartment of SurgeryKyoto Prefectural University of MedicineKyotoJapan
| | | | | | | | - Eigo Otsuji
- Division of Digestive SurgeryDepartment of SurgeryKyoto Prefectural University of MedicineKyotoJapan
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Gong J, Wang B, Wang J, Li Y, Cao Y, Li W, Shang M, Huang L. Continuous Jejunal Pouch and Residual Stomach Anastomosis Combined with Jejunal Lateral Anastomosis: An Improved Method of Gastrointestinal Reconstruction following Distal Gastrectomy. J INVEST SURG 2020; 35:293-300. [PMID: 33342314 DOI: 10.1080/08941939.2020.1854397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM Currently, there is no optimal digestive tract reconstruction technique well recognized by scholars after distal gastrectomy. A new reconstruction method, which was modified from the classic Roux-en-Y procedure, the continuous jejunal pouch and residual stomach anastomosis combined with jejunal lateral anastomosis (Contin-L), was established. In order to fully clarify the superiority of this procedure, this study has conducted a systematic analysis and prepared a summary of the clinical data of patients who underwent distal gastrectomy for gastric cancer. METHODS From June 2013 to March 2016, we enrolled 198 patients with gastric cancer who underwent radical D2 distal gastrectomy. According to the reconstruction methods, these patients were divided into three groups: Contin-L (n = 74), Billroth II (n = 59), and Roux-en-Y (n = 65) groups. The operation time for reconstruction, complications, prognostic nutritional index (PNI), and the Visick grading were analyzed. RESULTS Regarding long-term complications, such as reflux gastritis, the Contin-L procedure showed significantly better results than Billroth II (p < 0.0001). Regarding the long-term postoperative nutritional status, such as the PNI and body weight recovery, the Contin-L procedure displayed significantly better results than Billroth II and Roux-en-Y (p < 0.05). Postoperative subjective feelings evaluated by Visick grading were significantly more improved in the Contin-L than in the Billroth II and Roux-en-Y groups (p ≤ 0.01). CONCLUSIONS The Contin-L procedure gave full play to the advantages of jejunal continuity, and pouch and lateral anastomoses, which significantly reduced short- and long-term complications, and improved the long-term patient quality of life following the surgical procedure.
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Affiliation(s)
- JiaQing Gong
- Department of General Surgery, ChengDu XinHua Hospital, ChengDu, Sichuan Province, China
| | - Bin Wang
- Department of General Surgery, ChengDu XinHua Hospital, ChengDu, Sichuan Province, China
| | - JunQing Wang
- Department of Radiology, The General Hospital of Western Theater Command, ChengDu, Sichuan Province, China
| | - YunMing Li
- Depaartment of Medical Management, The General Hospital of Western Theater Command, ChengDu, Sichuan Province, China
| | - YongKuan Cao
- Center of General Surgery, The General Hospital of Western Theater Command, ChengDu, Sichuan Province, China
| | - Wei Li
- Department of General Surgery, ChengDu XinHua Hospital, ChengDu, Sichuan Province, China
| | - Min Shang
- Department of General Surgery, ChengDu XinHua Hospital, ChengDu, Sichuan Province, China
| | - Ling Huang
- Department of General Surgery, ChengDu XinHua Hospital, ChengDu, Sichuan Province, China
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Masaryk V, Meyer F, Will U. [Jejunojejunostomy by Interventional Endosonography (EUS) using "Lumen-apposing Metal Stent" (LAMS) in a Case of Obstructed Jejunal Loop after Former Gastrectomy: Video-Paper on a Typical Case]. Zentralbl Chir 2020; 146:446-449. [PMID: 33336344 DOI: 10.1055/a-1263-1648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Zusammenfassung
Einführung Um die Reservoirfunktion des Magens zu ersetzen und ein Postgastrektomiesyndrom zu vermeiden, wird nach einer Gastrektomie nicht selten ein jejunaler Pouch als Teil der Roux-en-Y-Ösophagojejunostomie zur anatomischen Resektion im oberen Gastrointestinaltrakt gebildet. Eine Abflussstenose mit Pouchdilatation, die mit konsekutiven abdominellen Beschwerden einhergeht, ist eine mögliche Spätkomplikation. Eine konservative Therapie bleibt oft ohne dauerhaften Erfolg, was meist eine operative Sanierung erforderlich macht. Eine endosonografisch geführte Jejunojejunostomie mit „Lumen-apposing Metal Stent“ (LAMS) ist dahingehend eine neue vielversprechende Therapieoption.
Fallpräsentation Bei einer 75-jährigen Patientin mit jejunalem Pouch nach vorheriger Gastrektomie wegen Magenkarzinoms (pT1b N1 [1/40] M0 L1 V1 G2 R0) traten seit Jahren wiederholt Beschwerden wie Erbrechen, postprandiale Bauchschmerzen und Krämpfe bei einer Abflussstörung des jejunalen Pouches mit einer konsekutiven Pouchdilatation auf. Konservative Therapie und Platzierung eines intestinalen Stents im stenotischen Abgang des abführenden Jejunalschenkels blieben ohne Erfolg. Es wurde eine endosonografisch geführte (EUS-geführte) Jejunojejunostomie mittels Hot-AXIOS-Stent-Platzierung (Boston Scientific, Ratingen, Deutschland) vom Pouchlumen aus zu einem aboralen Segment der hochgezogenen Jejunalschlinge angelegt. Seitdem (Follow-up: 12 Monate) war die Patientin dauerhaft beschwerdefrei mit konsekutiver Gewichtszunahme.
Diskussion und Schlussfolgerung Die Jejunojejunostomie mit EUS-geführter Einlage eines „LAMS“ bietet eine Alternative zu einer operativen Sanierung bei Stenose und Passageproblemen des jejunalen Pouches. Sie ist mit einer weit geringeren Invasivität, zügigeren Rekonvaleszenz und damit entscheidend verbesserter Lebensqualität verbunden.
Introduction In order to adequately replace the reservoir of the stomach and to avoid a post-gastrectomy syndrome, the anatomy of the upper gastrointestinal (GI) tract is reconstructed after gastrectomy – creating a jejunal pouch as part of Roux-en-Y oesophagojejunostomy. Stenosis of the efferent loop with pouch dilatation associated with subsequent abdominal discomfort and complaints can be considered a possible late complication. A conservative therapeutic approach is often unsuccessful and subsequent surgical intervention is necessary. Creation of an endosonography-guided jejunojejunostomy with a “lumen-apposing metal stent” (LAMS) is a novel and promising therapeutic option.
Case Presentation In a 75-years old woman with jejunal pouch after previous gastrectomy due to gastric cancer (pT1b N1 [1/40] M0 L1 V1 G2 R0), there had been recurrent complaints for years, such as vomiting, abdominal discomfort and postprandial pain as well as spasms because of disturbed GI passage via the efferent loop with consecutive pouch dilatation. Conservative measures and placement of an intestinal stent within the stenotic segment of the efferent jejunal loop did not result in permanent improvement. Therefore, endosonography-guided (EUS-guided) jejunojejunostomy was performed with a Hot-AXIOS stent (Boston Scientific, Ratingen, Germany) from the endoluminal site of the pouch to an aboral segment of the jejunal loop. At the 12-month follow-up, patient was permanently asymptomatic with resulting increase in body weight.
Discussion and Conclusion Jejunojejunostomy with EUS-guided implantation of an “LAMS” can be considered an alternative approach to surgery to solve problems with a strictured jejunal pouch due to disturbed GI passage. This is associated with far less invasiveness and traumatisation, prompt convalescence and, thus, substantially improved quality of life.
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Affiliation(s)
- Viliam Masaryk
- Klinik für Innere Medizin III (Gastroenterologie, Hepatologie und Allg. Innere Medizin), SRH Wald-Klinikum Gera gGmbH, Gera, Deutschland
| | - Frank Meyer
- Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland
| | - Uwe Will
- Klinik für Innere Medizin III (Gastroenterologie, Hepatologie und Allg. Innere Medizin), SRH Wald-Klinikum Gera gGmbH, Gera, Deutschland
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Pouch Versus No Pouch Following Total Gastrectomy: Meta-analysis of Randomized and Non-randomized Studies. Ann Surg 2019; 269:1041-1053. [DOI: 10.1097/sla.0000000000003082] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Long-term quality of life and nutrition status of the aboral pouch reconstruction after total gastrectomy for gastric cancer: a prospective multicenter observational study (CCOG1505). Gastric Cancer 2019; 22:607-616. [PMID: 30382468 DOI: 10.1007/s10120-018-0893-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several efforts have been made to alleviate harms and symptoms after gastrectomy for gastric cancer. We previously conducted a randomized controlled trial (CCOG1101) to compare quality of life (QOL) and nutritional status between Roux-en-Y (RY) and aboral pouch (AP) reconstructions for up to 1 year after total gastrectomy. However, long-term outcomes after AP reconstruction remain unclear. METHODS A prospective multicenter observational study was conducted to compare QOL, body composition, and nutritional indicators between the RY and AP reconstructions at 5 years after surgery among patients who were enrolled in the CCOG1101 trial. QOL was assessed by the PGSAS-37 questionnaires as well as the EORTC QLQ-C30 and STO22. RESULTS Sixty patients (31 for RY and 29 for AP) were recruited for analysis. There were no significant differences in baseline and perioperative characteristics between the two groups. No significant differences were found in the EORTC QLQ-C30 global health status and functional scales. Regarding symptom scales in the QLQ-C30 and STO22, a more favorable score for the diarrhea scale was observed in the AP group. Diarrhea was also the only item in the PGSAS-37 questionnaires in which significant benefit of AP was observed. Body weight and lean body mass continued to decrease throughout the postoperative 5 years in both groups. None of the conventional nutritional indicators using the serum samples showed significant difference between the two groups. CONCLUSIONS Long-term observation suggested little benefit of AP reconstruction after total gastrectomy other than in alleviating diarrhea.
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Takahashi M, Goto S, Ueno T, Shima K, Inoue K, Douchi D, Nishina O, Naito H. Extreme dilatation of the interposed jejunal pouch after proximal gastrectomy associated with portal venous gas: A case report. Int J Surg Case Rep 2017; 37:244-247. [PMID: 28715720 PMCID: PMC5514623 DOI: 10.1016/j.ijscr.2017.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/23/2017] [Accepted: 06/25/2017] [Indexed: 12/31/2022] Open
Abstract
Dilatation of the interposed jejunal pouch developed after proximal gastrectomy. Shock state with portal venous gas was restored after conservative therapy. The pouch dilatation recurred soon after resuming oral ingestion. Resection of the pouch with R-Y esophagojejunostomy relieved the patient. Surgical intervention should be considered for refractory pouch dilatation. Introduction The jejunal pouch interposition (JPI) after proximal gastrectomy (PG) was proposed as a reconstructive procedure to provide a gastric reservoir substitute and prevent postgastrectomy syndrome. However, food residue remaining in some of the pouches resulted in the adverse effect of abdominal bloating, thereby body weight loss. Here, we report a rare case with an extreme dilation of the interposed jejunal pouch (JP) 8 years after PG, requiring pouch resection. Presentation of case A 65-year-old-man who had undergone PG with an inverted U-shaped JPI for early gastric cancer 8 years previously, suffered from shock after right hip joint implantation. Abdominal enhanced CT scan revealed an extremely dilated JP accompanied by portal venous gas. After 5 months of conservative therapy, he underwent resection of the JP and gastric remnant with Roux-en-Y esophagojejunostomy reconstruction. After the operation, the patient has remained in good health for over 3 years. Discussion and conclusion Long-term operative outcome following pouch operation for gastric cancer still remains controversial. Surgical intervention should be considered when we encounter patients who have refractory pouch dilatation after surgery for gastric cancer.
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Affiliation(s)
- Michinaga Takahashi
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Shinji Goto
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Tatsuya Ueno
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Kentaro Shima
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Koetsu Inoue
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Daisuke Douchi
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Orie Nishina
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
| | - Hiroo Naito
- Department of Surgery, South Miyagi Medical Center, 38-1 Aza Nishi, Ogawara, Shibata-gun, Miyagi, 989-1253 Japan.
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11
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Maeda H, Namikawa T, Okamoto K, Munekage E, Toi M, Hiroi M, Takeshita A, Hanazaki K, Kobayashi M. Dilation and stasis: a rare but important late complication of jejunal pouch interposition after proximal gastrectomy. ANNALS OF CANCER RESEARCH AND THERAPY 2017; 25:17-21. [DOI: 10.4993/acrt.25.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Ken Okamoto
- Cancer Treatment Center, Kochi Medical School Hospital
| | - Eri Munekage
- Department of Surgery, Kochi Medical School, Kochi University
| | - Makoto Toi
- Department of Diagnostic Pathology, Kochi Medical School Hospital
| | - Makoto Hiroi
- Department of Diagnostic Pathology, Kochi Medical School Hospital
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A long-term follow-up result of pouch plasty for severe dysfunction of jejunal pouch reconstruction after total gastrectomy: a case report. Int Surg 2016; 100:954-7. [PMID: 26011222 DOI: 10.9738/intsurg-d-14-00181.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A 78-year-old woman with malignant lymphoma of the stomach underwent total gastrectomy with a jejunal-pouch (J-pouch) reconstruction in 1994. Twelve years after surgery the patient began to suffer epigastric distress and reflux symptoms. Eventually, she was unable to take anything by mouth. A series of diagnostic images seemed to indicate that the main cause of the dysfunction was flaccidity of the J-pouch and deformity of the outflow route induced by chronic excessive dilatation of the pouch wall. Because all conservative managements only led to temporary improvement and ended in failure, she hoped to receive the operation. We designed "pouch plasty" capable of ameliorating the pouch dysfunction. The aim of pouch plasty was to improve uneven tension of the pouch wall and repair deformity of the outflow route of the food. After the operation, the J-pouch resumed adequate drainage and had good reservoir function. More than 7 years later, the patient had no further complications.
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Gong JQ, Cao YK, Zhang GH, Wang PH, Luo GD. Uncut Esophagojejunostomy with Double Jejunal Pouch: An Alternative Reconstruction Method that Improves the Quality of Life of Patients after Total Gastrectomy. J INVEST SURG 2016; 30:125-132. [DOI: 10.1080/08941939.2016.1230249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Nomura E, Okajima K. Function-preserving gastrectomy for gastric cancer in Japan. World J Gastroenterol 2016; 22:5888-5895. [PMID: 27468183 PMCID: PMC4948261 DOI: 10.3748/wjg.v22.i26.5888] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/30/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
Surgery used to be the only therapy for gastric cancer, and since its ability to cure gastric cancer was the focus of attention, less attention was paid to function-preserving surgery in gastric cancer, though it was studied for gastroduodenal ulcer. Maki et al developed pylorus-preserving gastrectomy for gastric ulcer in 1967. At the same time, the definition of early gastric cancer (EGC) was being considered, histopathological investigations of EGC were carried out, and the validity of modified surgery was sustained. After the development of H2-blockers, the number of operations for gastroduodenal ulcers decreased, and the number of EGC patients increased simultaneously. As a result, the indications for pylorus-preserving gastrectomy for EGC in the middle third of the stomach extended, and various alterations were added. Since then, many kinds of function-preserving gastrectomies have been performed and studied in other fields of gastric cancer, and proximal gastrectomy, jejunal pouch interposition, segmental gastrectomy, and local resection have been performed. On the other hand, from the overall perspective, it can be said that endoscopic resection, which was launched at almost the same time, is the ultimate function-preserving surgery under the current circumstances. The current function-preserving gastrectomies that are often performed and studied are pylorus-preserving gastrectomy and proximal gastrectomy. The reasons for this are that these procedures that can be performed with systemic lymph node dissection, and they include three important elements: (1) reduction of the extent of gastrectomy; (2) preservation of the pylorus; and (3) preservation of the vagal nerve. In addition, these operations are more likely to be performed with a laparoscopic approach as minimally invasive surgery. Of the above-mentioned three elements, reduction of the extent of gastrectomy is the most important in our view. Therefore, we should try to reduce the extent of gastrectomy if curability of the gastric cancer can still be achieved. However, if we preserve a wider residual stomach in function-preserving gastrectomy, we should pay attention to the development of metachronous gastric cancer.
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Namikawa T, Munekage E, Munekage M, Maeda H, Kitagawa H, Nagata Y, Kobayashi M, Hanazaki K. Reconstruction with Jejunal Pouch after Gastrectomy for Gastric Cancer. Am Surg 2016. [DOI: 10.1177/000313481608200611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The construction of a gastric substitute pouch after gastrectomy for gastric cancer has been proposed to help ameliorate postprandial symptoms and nutritional performance. Adequate reconstruction after gastrectomy is an important issue, because postoperative patient quality of life (QOL) primarily depends on the reconstruction method. To this end, jejunal pouch (JP) reconstructions were developed to improve the patient's eating capacity and QOL by creating large reservoirs with improved reflux barriers to prevent esophagitis and residual gastritis. It is important that such reconstructions also preserve blood and extrinsic neural integrity for maintaining pouch function, because JP motility is associated directly with QOL. Some problems remain to be resolved with the JP reconstructions method including gastrointestinal motility, which plays a major role in food transfer, digestion, and absorption of nutrients. Further studies including basic research and larger prospective randomized control trials are also needed to obtain definitive results. With persistent innovations in surgical techniques, JP after gastrectomy could become a safe and preferable reconstructive modality to improve patient QOL after gastrectomy.
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Affiliation(s)
| | - Eri Munekage
- Department of Surgery, Kochi Medical School, Nankoku, Japan
| | | | - Hiromichi Maeda
- Cancer Treatment Center, Kochi Medical School Hospital, Nankoku, Japan
| | | | - Yusuke Nagata
- Department of Surgery, Izumino Hospital, Kochi, Japan
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Yasuda A, Yasuda T, Imamoto H, Kato H, Nishiki K, Iwama M, Makino T, Shiraishi O, Shinkai M, Imano M, Furukawa H, Okuno K, Shiozaki H. A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy. Gastric Cancer 2015; 18:850-8. [PMID: 25318978 DOI: 10.1007/s10120-014-0431-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/27/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem. METHODS We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005. RESULTS Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group. CONCLUSIONS The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.
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Affiliation(s)
- Atsushi Yasuda
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Takushi Yasuda
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Haruhiko Imamoto
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hiroaki Kato
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Kohei Nishiki
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Mitsuru Iwama
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Tomoki Makino
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Osamu Shiraishi
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Masayuki Shinkai
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Motohiro Imano
- Cancer Center, Kinki University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hiroshi Furukawa
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Kiyokata Okuno
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hitoshi Shiozaki
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
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Nakamura M, Yamaue H. Reconstruction after proximal gastrectomy for gastric cancer in the upper third of the stomach: a review of the literature published from 2000 to 2014. Surg Today 2015; 46:517-27. [PMID: 25987497 DOI: 10.1007/s00595-015-1185-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/28/2015] [Indexed: 12/14/2022]
Abstract
Proximal gastrectomy (PG) is occasionally performed to preserve the physiological function of the remnant stomach with the aim of maintaining a gastric reservoir for patients with early gastric cancer in the upper third of the stomach. Many reconstructive procedures after PG have been reported, including esophagogastrostomy (EG), jejunal interposition, jejunal pouch interposition, and double tract. However, no general agreement exists regarding the optimal reconstructive procedure. This article reviews the current reconstructive procedures available for PG. We examined the surgical outcomes, postoperative complications, endoscopic findings, and quality of life (QOL) according to the reconstructive procedures. We found no significant difference in anastomotic leakage and anastomotic stricture among the procedures. The frequency of reflux esophagitis was higher with simple EG compared with the other reconstructive procedures. Some additional procedures, such as fundoplication, the use of a narrow gastric conduit, and placement of a gastric tube in the lower mediastinum on EG, could decrease the frequency of reflux esophagitis and reflux symptoms. These additional procedures may improve the QOL; however, the previous studies were small and could not adequately compare the reconstructive procedures. Prospective randomized controlled trials that involve a longer trial period and more institutions are needed to clarify the optimal reconstructive procedures after PG.
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Affiliation(s)
- Masaki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
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Zhang H, Sun Z, Xu HM, Shan JX, Wang SB, Chen JQ. Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction. World J Gastroenterol 2009; 15:3183-90. [PMID: 19575501 PMCID: PMC2705744 DOI: 10.3748/wjg.15.3183] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare postoperative quality of life (QOL) in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy.
METHODS: QOL assessments that included functional outcomes (a 24-item survey about treatment-specific symptoms) and health perception (Spitzer QOL Index) were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy.
RESULTS: Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty (EA group); 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis (EP group); and 50 patients had reconstruction by esophagogastric end-to-end anastomosis (EE group). The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups.
CONCLUSION: Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.
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Serious complications after a proximal gastrectomy with a jejunal pouch interposition for gastric cancer. Clin J Gastroenterol 2009; 2:183-186. [DOI: 10.1007/s12328-009-0067-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2008] [Accepted: 02/01/2009] [Indexed: 11/26/2022]
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Gao JS, Wang ZJ, Wei GH, Song WL, Yi BQ, Gao ZG, Zhao B, Liu Z, Li A. Deep venous thrombosis after gastrectomy for gastric carcinoma: A case report. World J Gastroenterol 2009; 15:885-7. [PMID: 19230054 PMCID: PMC2653393 DOI: 10.3748/wjg.15.885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The treatment of gastric carcinoma consists of neoadjuvant chemoradiation, partial gastrectomy, subtotal gastrectomy, total gastrectomy, extended resection, and postoperative chemotherapy. Currently, gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma. Postoperative complications are common after total gastrectomy including hemorrhage, anastomotic leakage, fistula, and obstruction. However, deep venous thrombosis (DVT) is an uncommon complication after gastrectomy for gastric carcinoma. We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma. The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring. The patient recovered well after treatment and was symptom-free during a 3-mo follow-up. We conclude that correct diagnosis and treatment of DVT are crucial.
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