Near-Total Gastrectomy Preserving the Lower Esophageal Sphincter Followed by Jejunal Pouch Interposition as a Treatment for Upper Gastric Cancer

PURPOSE: Conventional total gastrectomy with Roux-en-Y esophagojejunostomy has certain limitations such as insufficient food reservoir and malabsorption of nutrients. Therefore, we performed reconstruction of the jejunal pouch interposition (JPI) after near-total gastrectomy preserving the lower esophageal sphincter (LES). We compared the technical feasibility, safety, and surgical outcome of this operation with conventional total gastrectomy accompanying with Roux-en-Y esophagojejunostomy. METHODS: From April 2003 to October 2005, 15 LES-preserving, near-total gastrectomies with JPI (LES-JPI group) were performed. The clinical features and surgical outcomes were retrospectively compared with 17 cases of conventional R-Y esophagojejunostomy. Statistical analysis was performed using Fisher's exact test for categorical data and an unpaired t-test for continuous data. RESULTS: Clinicopathological features of the LES-JPI and R-Y groups did not show differences excepting patient age (50.8+/-5.8 years vs. 62.8+/-12.4, respectively; P=0.002) and the depth of tumor invasion (T1-T2; 11~4 vs. 5~12; P=0.032). The operative outcomes for the two groups significantly differed in terms of operation time (676 vs. 484 min; P=0.008) and blood loss (424 vs. 336 ml; P=0.006). Postoperative gastrofiberscopic examination of all LES-JPI patients showed no esophageal reflux or strictures and intact LES. In addition, the LES-JPI group did not experience swallowing difficulty or stricture. CONCLUSION: LES-preserving total gastrectomy with JPI is a feasible and safe procedure for patients with upper gastric cancer.

Comparison of Reconstructive Techniques after Total Gastrectomy as Determined by Patient Quality of Life and Nutritional Status

PURPOSE: Many reconstruction procedures have been developed in order to resolve patient complaints after a total gastrectomy. However, until now, there has been no general agreement with regard to the ideal reconstruction to perform after a total gastrectomy. Moreover, there have been few reports of the long-term effects of different reconstruction procedures. In this study, we compared the long-term nutritional status and quality of life for patients that received either a Roux-en-Y esophagojejunostomy (R-Y), jejunal interposition (JI), jejunal pouch interposition (JPI), or double tract reconstruction (DT), to determine the optimum reconstruction procedure after a total gastrectomy. MATERIALS AND METHODS: The study consisted of 41 patients younger than 80 years who had undergone a total gastrectomy with curative resection and who had no evidence of recurrence at our hospital between August 2000 and January 2004. The patients were classified into the following four groups, according to the type of reconstruction; simple Roux-en-Y (R-Y group, n=15), jejunal interposition (JI; group, n=8), j Jejunal pouch interposition (JPI group, n=8), double tract interposition (DT group, n=10). The nutritional status was assessed by measuring body weight, serum albumin level, serum hemoglobin level, and the level of serum total protein, and the PNI (Prognostic nutritional index). Quality of life was assessed by GSRS. In addition, endoscopy was performed to confirm the presence of reflux esophagitis. RESULTS: The laboratory findings showed no significant differences between the four groups except for a lower total protein and album level in the DT group after 3 years postoperatively (P=0.006, P=0.033). The percentage of body weight at 1 year, and 3 years postoperatively in the JI group (P=0.013, P=0.011) were significantly less than other groups (P=0.011, P=0.000). The frequency of postoperative symptoms and reflux esophagitis and eating capacity showed no significant differences between the four groups. The GSRS score in the JIP group was significantly better than for the other groups at 1 year, and 3 years postoperatively (P=0.028, P=0.003). CONCLUSION: We believe that the jejunal pouch interposition is the most useful of the four procedures for improving postoperative quality of life.

Proximal Gastrectomy Reconstructed by Jejunal Pouch Interposition: Surgical Technique and Evaluation of Postoperative Function

PURPOSE: Total gastrectomy has generally been performed for the treatment of upper third gastric cancer. However, the optimal extent of resection for the upper third gastric cancer is controversial until now. This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by jejunal pouch interposition. METHODS: We have used interposition of a double jejunal pouch between the esophagus and the remnant stomach after performing proximal gastrectomy in 22 patients to date. The postoperative courses were compared with those of 23 patients who underwent total gastrectomy during the same period. RESULTS: The age of the patients ranged from 28 to 72 years (mean 56.4 years); 18 were men and 4 were women. The lesions were mostly located along the lesser curvature or at the posterior wall. Histological examination showed that 13 patients had early gastric cancer, seven had advanced cancer, and two had malignant GISTs. Lymph node metastasis was observed in two patients. The comparative study revealed that there were no significant differences in the operation time and the length of hospital stay. There was no anastomotic leakage or intraabdominal abscess, and no operative deaths. Other complications were anastomotic stricture in 2 patients, pouch bleeding in one, pouch ulcer in one, and delayed emptying in two patients. No other symptoms, including dumping or reflux esophagitis, were recognized in any of the patients. CONCLUSION: Proximal gastrectomy reconstructed with jejunal pouch interposition was a safe procedure and led to a better quality of life, as judged from the functional studies in our patients. However, long term follow-up results of quality of life and survival will be necessary to confirm the superiority of this procedure.