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.

Emptying of the jejunal pouch and Roux-en-Y limb after total gastrectomy--a randomised, prospective study.

OBJECTIVE: To investigate the emptying of solids after total gastrectomy with pouch reconstruction. DESIGN: Randomised, prospective study. SETTING: University hospital, Finland. SUBJECTS: 49 patients with gastric carcinoma operated on for cure between 1988 and 1992. INTERVENTIONS: After total gastrectomy 26 patients were randomised to have a pouch reconstruction and 23 a Roux-en-Y reconstruction. 15 months after the operation 24 patients with a pouch (pouch group) and 21 patients with a simple Roux-en-Y reconstruction (Roux-en-Y group) were alive and available to have an emptying test by the solid isotope method. Emptying of the pouch and Roux-en-Y limb was assessed by measuring the activity at 3 hours. MAIN OUTCOME MEASURES: Postoperative symptoms, size of meal, and postoperative nutrition. RESULTS: Emptying was significantly slower after pouch reconstruction than after Roux-en-Y (mean activity at 3 hours 82% and 44%, respectively, p < 0.01). Early satiety occurred in 10 (48%) of the patients after Roux-en-Y reconstruction and 6 (25%) in the pouch group. Dumping was more common in the Roux-en-Y group (n = 12, 57% compared with n = 6, 25%, p = 0.04). 19 (79%) of the patients in the pouch group were able to eat normal sized meals compared with 3 (14%) in the Roux-en-Y group (p < 0.0001). Weight gain and haemoglobin and albumin concentrations were similar in the two groups. CONCLUSION: Jejunal pouch reconstruction after total gastrectomy delays passage of solid food in the upper intestine compared with Roux-en-Y reconstruction. It is associated with better eating capacity and fewer postoperative symptoms.

Bacterial overgrowth, intestinal transit, and nutrition after total gastrectomy. Comparison of a jejunal pouch with Roux-en-Y reconstruction in a prospective random study.

BACKGROUND: Jejunal pouches after total gastrectomy have been introduced to diminish postgastrectomy symptoms and improve nutrition. However, the effect of a pouch on the intestinal bacteriology and transit is controversial. METHODS: Bacterial overgrowth was measured with the glucose breath test and the mouth-to-caecum transit time (MCT) by means of the lactulose breath test after total gastrectomy and Roux-en-Y reconstruction in 24 patients with a pouch (Pouch group) and in 22 patients without a pouch (Roux-en-Y group). Postoperative symptoms were evaluated with a standard questionnaire, and nutrition was measured by blood chemistry and weight loss. RESULTS: MCTT was 110 +/- 44 min in the Roux-en-Y group and 117 +/- 44 min in the Pouch group (NS). Eighty-six per cent of the patients in the Roux-en-Y group and 91% of the patients in the Pouch group had bacterial overgrowth (NS). Transit time was shorter in patients with severe dumping than patients without dumping (60 +/- 28 min versus 115 +/- 41 min; P = 0.04). Maximal hydrogen concentration in the glucose breath test correlated negatively with serum albumin and iron concentrations and with postoperative weight loss, and positively with serum alkaline phosphatase activity. CONCLUSIONS: Bacterial overgrowth is common in the upper intestine after total gastrectomy. Pouch reconstruction does not delay the transit of liquids. Bacterial overgrowth may be one of the main aetiologic factors in postgastrectomy malnutrition.