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.

Clinical outcome of proximal gastrectomy in patients with early gastric cancer in the upper third of the stomach.

OBJECTIVE: To determine whether clinical outcomes after proximal gastrectomy are better than those after total gastrectomy with Roux-en Y reconstruction. METHODS: We studied 10 consecutive patients with early gastric cancer who underwent esophagogastrostomy after proximal gastrectomy (PG group). Nutritional variables in these patients were compared with those in 10 consecutive patients who underwent Roux-en Y reconstruction after total gastrectomy (TG group). Patients were followed up for 5 years after operation. RESULTS: There was no anastomotic leakage. The total cholesterol level 1 year after operation was higher in the PG group than in the TG group (p< 0.05). Body mass index was significantly lower than the preoperative value between 1 month and 2 years postoperation in the PG group, whereas the TG group showed decreases between 3 months to 5 years postoperation. The percent decreases in body weight at 3 and 4 years in the PG group were lower than those in the TG group (both p< 0.05). Postoperative weight loss was thus milder in the PG group than in the TG group. CONCLUSION: Esophagogastrostomy after PG may produce better clinical outcomes than Roux-en Y reconstruction after TG in patients with early gastric cancer arising in the upper third of the stomach.

Esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach.

OBJECTIVE: This study was designed to assess the outcome of esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach. METHODS: From 1997 through 2004, we studied 10 consecutive patients. A stapler was introduced into the stomach, and an esophagogastrostomy was performed before proximal gastrectomy. Hill's posterior gastropexy and Dor's anterior fundic wrap were performed to prevent reflux esophagitis. RESULTS: The operation time was 171 ± 44 minutes, and the intraoperative bleeding volume was 294 ± 228 mL. There was no anastomotic leakage. Anastomotic stenosis, occurring in 40% of the patients, required endoscopic balloon dilatation. Symptoms of reflux esophagitis, occurring in 40% of the patients, resolved within 2 years after operation. As compared with the preoperative value, body mass index was significantly decreased 1 and 2 years after operation, but was similar at 3 to 5 years. The percent decrease in body weight after operation fluctuated between 6% and 8% between 2 and 5 years. Postoperative weight loss was thus mild. CONCLUSIONS: Esophagogastrostomy before proximal gastrectomy may be less invasive, simpler, and produce better outcomes than conventional procedures for the surgical treatment of early gastric cancer in the upper third of the stomach.

Laparoscopic treatment of intestinal intussusception in Peutz-Jeghers syndrome: case report and review of literature.

A 47-year-old woman presented with an abdominal mass and nausea. Abdominal ultrasound and computed tomography (CT) showed a sausage-shaped mass with invagination. One polyp that appeared to exceed 3 cm was found in the sigmoid colon. Laparoscopy confirmed an intussusception mass, and the intussusception was dissected by hand-assisted laparoscopy (HALS). The sigmoid colon was also mobilized to the site of the small incision and resected. Generally, we believe enterectomy including polyps should be avoided as much as possible in Peutz-Jeghers syndrome (PJS) because poly-surgery may lead to short bowel syndrome. In addition, PJS patients often undergo multiple surgery, and therefore dense intra-abdominal adhesions are seen at subsequent laparotomy, which makes surgery increasingly difficult with repeated operations. Laparoscopic-assisted surgery seems beneficial, as in the present case.

Focus on the conditions of resection and reconstruction in gastric cancer. What extent of resection and what kind of reconstruction provide the best outcomes for gastric cancer patients?

To assess the roles of the extent of gastric resection and duodenal food passage reconstruction in gastric cancer, we examined a consecutive series of 1,061 patients who underwent total or partial (proximal and distal) gastrectomies with or without duodenal food passage reconstruction between August of 1974 and January of 2002, and received gastrectomies with D2-3 lymph node dissection. Patients who underwent distal or proximal gastrectomy were found to have significantly better survival rates than those who underwent total gastrectomy in stages 1A (10-year survival: 86.6 and 78.9 vs. 61.6%), 2 (56.5 and 65.6 vs. 34.4%), 3A (45.9 and 33.3 vs. 15.2%), and 4 (5-year survival rates: 23.7 and 50.0 vs. 7.1%). Additionally, patients with duodenal food passage reconstruction or double tract reconstruction also showed significantly better survival rates than those without duodenal food reconstruction in stages 1A (10-year survival: 86.4 and 82.5 vs. 61.7%), 1B (69.9 and 90.6 vs. 54.1%), 2 (60.5 and 63.3 vs. 16.5%), and 3A (39.9 and 47.4 vs. 23.1%). In multivariate analysis, the independent prognostic factors were age at operation, depth of tumor, duodenal food passage reconstruction, and lymph node metastasis. Our results indicate that both the extent of gastric resection and duodenal food passage reconstruction were important factors in the outcome of gastric cancer patients, and that surgeons should perform minimal gastric resection with preservation of the duodenal food passage when the gastric stump is tumor-free.

A case of primary small intestinal cancer diagnosed by laparoscopy.

The patient was a 61-year-old female who developed ileus. Physical findings showed abdominal distension but peritoneal irritation signs were not observed. After the conservative treatment by the ileus tube, encircling stenosis was observed in the jejunum at about 50 cm on the anal side from the Treitz ligament on contrast radiography of the small intestine through the ileus tube. Tumor markers were normal except for mild elevation of IL2-R (609 U/ml). After confirming sufficient bowel decompression and the absence of other lesions, surgery was performed based on a preoperative diagnosis of small intestinal tumor including adhesive ileus, GIST, or malignant lymphoma. First, under the laparoscopic observation, the lesion was resected and definitive diagnosis was established as primary moderately to poorly differentiated adenocarcinoma of the small intestine by rapid intraoperative pathological diagnosis. Then, extensive jejunal resection involving sufficient lymph node dissection was performed as open surgery. Radical surgery was successfully performed.

[A case of advanced gastric cancer with multiple liver metastases responding to TS-1 and CDDP].

A 44-year-old male presented to our hospital with abdominal pain. The upper endoscopy revealed advanced gastric cancer. On the abdominal CT, there was evidence of multiple, massive liver metastases. After total gastrectomy, the patient was treated with daily oral administration of 120 mg TS-1 for 4 weeks followed by 2 weeks' rest and 6 weekly infusions of 10 mg CDDP in an intra-hepatic artery as 1 cycle. On the follow-up CT, the liver metastases had decreased significantly both in size and number after 2 cycles. The current case suggests that TS-1 and CDDP may have a potent therapeutic efficacy in cases of advanced gastric cancer with multiple liver metastases.

Tracheal agenesis: a case report.

Tracheal agenesis is a rare congenital anomaly which results inevitably in immediate respiratory distress after delivery. Since the first report of the case in 1900, more than 150 cases reported in the Japanese and world literature. Attempts to save these children have failed to permit survival although a slight prolongation of life was achieved in some. We treated a baby girl with tracheal agenesis associated with other multiple anomalies and surgical intervention was attempted but without success due to incorrectable anatomy. Herein we describe her clinical picture and autopsy findings. Along with a review of the Japanese literature, we discuss this rare anomaly in terms of its anatomy, associated anomalies, pathogenesis, and clinical management.