Comparison of the Physiological Effect of Billroth-I and Roux-en-Y Reconstruction Following Laparoscopic Distal Gastrectomy.

BACKGROUND: Laparoscopic distal gastrectomy (LDG) is a widely used minimally invasive surgery. Following LDG, Billroth-I (B-I) provides physiological reconstruction by preserving the duodenal passage but results in a high incidence of reflux esophagitis that decreases postoperative quality of life. Because of this, Roux-en-Y (R-Y) reconstruction is often considered the first choice after LDG. However, very few studies have investigated differences in physiological function between B-I and R-Y after LDG. We hypothesized that B-I would outperform R-Y in clinical and physiological outcomes, including nutrition parameters. METHODS: We compared hemoglobin, ferritin, serum iron, Vitamin B12, 25(OH)-Vitamin D (V-D), body weight, and gastric emptying after LDG in patients with either B-I or R-Y reconstruction. RESULTS: The levels of hemoglobin in the B-I group were significantly higher than that in the R-Y group at all time points later than 6 months postsurgery. The ferritin levels were significantly higher in the B-I group at all time points later than 9 months postsurgery. The concentration of serum V-D in the B-I group was significantly higher than that in the R-Y group at 1 year 6 months, 1 year 9 months, and 2 years after surgery. Gastric emptying in the R-Y group was significantly slower than in the B-I group. CONCLUSIONS: Our data indicate that B-I leads to less postsurgical iron deficiency anemia and V-D deficiency compared with R-Y reconstruction. Furthermore, gastric emptying was preserved in B-I reconstruction compared with R-Y reconstruction. In conclusion, after LDG, B-I reconstruction seems to cause fewer nutritional complications than R-Y reconstruction.

Impact of gastropyloric motor activity on the genesis of reflux esophagitis after an esophagectomy with gastric tube reconstruction.

BACKGROUND: Reflux esophagitis is a significant problem in patients after an esophagectomy with gastric tube reconstruction. The pathogenesis of reflux esophagitis is not fully understood. The aim of the present study was to evaluate whether gastropyloric motility influences the pathogenesis of reflux esophagitis after an esophagectomy. METHODS: Thirty esophagectomized patients were assessed by endoscopy and manometry. The patients were classified into 3 groups according to the postoperative period as follows: Group 1 (less than 12 months), group 2 (12 to 24 months), and group 3 (more than 24 months). Gastropyloric motor activity was quantified by calculating the motility index, which is equivalent to the area under the contractile waves. RESULTS: Reflux esophagitis was observed in 80% of group 1, 80% of group 2, and 30% of group 3. The severity of reflux esophagitis decreased with time. Contractions of the gastric body were not observed in any of the patients. The antral motility index in group 3 was significantly greater than that in groups 1 and 2. The pyloric motility index progressively increased. The severity of reflux esophagitis is significantly associated with gastropyloric motor activity. CONCLUSIONS: The severity of reflux esophagitis decreases with time, coupled with recovery of antropyloric motor activity. Gastropyloric motor activity plays an important role in the genesis of reflux esophagitis after an esophagectomy.

Gastric motor activity in gastric pull-up esophagectomized patients with and without reflux symptoms.

BACKGROUND: Patients frequently experience reflux symptoms of heartburn and regurgitation after a gastric pull-up esophagectomy. The pathogenesis of reflux symptoms is not fully understood. The gastrointestinal tract exhibits a temporally coordinated cyclic motor pattern, termed interdigestive migrating motor contraction, during the interdigestive state. Phase III of interdigestive migrating motor contraction is important in cleaning indigestible solids and basal secretions. Impairment of phase III may result in reflux symptoms of heartburn and regurgitation. The present study evaluated whether gastropyloroduodenal motility after gastric pull-up esophagectomy influences the pathogenesis of reflux symptoms. METHODS: Gastropyloroduodenal motility was recorded by manometry in 20 patients after a gastric pull-up esophagectomy. Esophagectomized patients were questioned about the presence of heartburn or regurgitation, or both. RESULTS: Of 20 patients, 8 (40%) were considered the symptomatic group. Phase III, in which contractions originating from the antrum migrate to the pylorus and then move to the duodenum, was observed in only 1 of 8 patients. In the asymptomatic group, phase III was observed in 8 of 12 patients. A significant correlation was found between the presence of reflux symptoms and the paucity of phase III activity (p=0.02). CONCLUSIONS: The presence of reflux symptoms after gastric pull-up esophagectomy is significantly associated with the paucity of gastric phase III. Gastric motor activity is important in the occurrence of reflux symptoms.

The utility of a noninvasive 13C-acetate breath test to predict quality of life after gastrectomy.

BACKGROUND: The radioscintigraphic technique has been accepted as the standard by which to measure gastric emptying but it is invasive and expensive. A 13C-acetate breath test was reported to be a noninvasive and reliable method. The aim of this study was to investigate the accuracy of a 13C-acetate breath test in reflecting gastric function and the relationship between food intake and change in body weight after distal gastrectomy. METHODS: Twenty-five patients who had undergone curative distal gastrectomy with Billroth-I reconstruction for gastric cancer and ten healthy volunteers were included in the study. The gastrectomy group was divided into two groups: the stasis group and the nonstasis group. The breath test was performed on the patients with gastrectomy and the healthy volunteers, and the time lag between ingestion and the peak of (13)CO(2) expiration (T lag) was calculated. The manometry study was performed on the patients who underwent gastrectomy and the motility index (MI) was calculated. The relationships between T lag and food intake and body weight were examined. RESULTS: The T lag was significantly shorter in the nonstasis group than in the stasis group. The MI in the duodenum in the nonstasis group was significantly larger than that in the stasis group. There was significant correlation between T lag and food intake, but no significant correlation between T lag and body weight. CONCLUSION: The 13C-acetate breath test might be useful not only for the evaluation of the function of the remnant stomach, but also for the prediction of postoperative status.

The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats.

BACKGROUND: Clinical studies show that disturbed colonic motility induced by extrinsic nerves damage is restored over time. We studied whether 5-HT3 and 5HT4 receptors are involved in mediating the adaptive mechanisms following parasympathetic denervation. METHODS: Parasympathetic denervation of the entire colon was achieved by bilateral pelvic nerve transection and truncal vagotomy in rats. Colonic transit was measured by calculating the geometric center (GC) of 51Cr distribution. Expression of 5-HT3 and 5HT4 receptor mRNA was determined by real time RT-PCR. RESULTS: Parasympathetic denervation caused a significant delay in colonic transit (GC=4.36) at postoperative day (POD) 1, compared with sham operation (GC=6.31). Delayed transit was gradually restored by POD 7 (GC=5.99) after the denervation. Restored colonic transit was antagonized by the administration of 5-HT3 and 5HT4 receptors antagonists at POD 7. 5-HT3 and 5HT4 receptors mRNA expression were significantly increased in the mucosal/submucosal layer at POD 3 or POD 7, whereas no significant difference was observed in the longitudinal muscle layers adherent with the myenteric plexus (LMMP). CONCLUSIONS: It is suggested that up-regulation of 5-HT3 and 5-HT4 receptors expression in the mucosal/submucosal layer is involved to restore the delayed transit after the parasympathetic denervation in rats.

Effect of distal subtotal gastrectomy with preservation of the celiac branch of the vagus nerve to gastrointestinal function: an experimental study in conscious dogs.

OBJECTIVE: To evaluate the effects of distal subtotal gastrectomy with preservation of the celiac branch of the vagus nerve on gastrointestinal function. SUMMARY BACKGROUND DATA: The operative procedure of distal subtotal gastrectomy with preservation of the celiac branch of the vagus nerve is now in the spotlight in Japan with the goal of finding a function-preserving surgical technique. However, there has been no analysis of the effect of this type of surgery on gastrointestinal function. In this article, we describe the results of a fundamental experiment on distal subtotal gastrectomy with preservation of the celiac branch of the vagus nerve. METHODS: Twenty conscious dogs were divided into 2 groups, each subdivided into 2 groups of 5: a normal intact dog group (NG) divided into 2 groups, with preservation (PNG) and resection (RNG; these dogs were truncally vagotomized including transaction of the celiac branch) of the celiac branch, and a gastrectomy dog group (GG) divided into 2 groups, with preservation (PGG) and resection (RGG) of the celiac branch. The motility of the dogs was recorded using strain gauge force transducers. The effects of the preservation of the celiac branch of the vagus nerve on gastrointestinal motility, gastric emptying, and pancreatic insulin release were evaluated. RESULTS: The motility index of gastrointestinal motility with preservation of the celiac branch was higher than the motility index with resection of the celiac branch in fasted and fed of NG and GG. In gastric emptying, significant differences were found between the PNG and RNG but not between the PGG and RGG. In the fasted state for 80 minutes of the PNG and PGG, the serum insulin concentration reached a peak during the early phase III at 20 minutes in the gastric body and the antrum. CONCLUSIONS: This study has shown that it is effective to preserve the celiac branch of the vagus nerve for gastroduodenal motility, gastric emptying, and pancreatic insulin release after a gastrectomy.

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction.

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.

Peritoneal recurrence of gastric cancer with mucin phenotype 12 years after curative resection: report of a case.

We report a case of peritoneal recurrence of gastric cancer in a 58-year-old man, 12 years after curative surgery. Urinary wall thickness was seen on follow-up computed tomography and magnetic resonance imaging scans. We performed total nephroureterectomy and cystectomy for urinary tract cancers, but histological examination of the resected specimen revealed poorly differentiated adenocarcinoma with severe fibrosis, resembling the gastric cancer resected 12 years earlier. Immunohistological examination revealed human gastric mucin (45M1) and intestinal mucin (MUC2) phenotype in both the original gastric cancers and the urinary tract cancers. Thus, we concluded that the second cancer was a peritoneal recurrence of gastric cancer with gastric and intestinal mucin phenotypes. Although peritoneal recurrence so many years after curative gastrectomy is rare, careful long-term follow-up should be done for all patients undergoing surgery for gastric cancer with mucin phenotype.

Matrilsin expression is a useful marker of submucosal invasion and lymph node metastasis in early stage signet ring cell carcinoma of the stomach.

BACKGROUND: Matrilysin (MMP-7) is considered to play an important role in tumor progression and metastasis. The aim of this study was to examine the MMP-7 expression of early-stage undifferentiated gastric carcinoma, and to investigate differences between gastric signet ring cell (SIG) and other undifferentiated carcinomas (non-SIG). METHODS: Immunohistochemical staining of MMP-7 was performed using specimens from 150 patients with early-stage gastric undifferentiated carcinomas (76 SIG, 74 non-SIG). RESULTS: SIG had a larger proportion of mucosal-confined carcinoma and a lower rate of lymphatic invasion than non-SIG (P < 0.05). The incidence of the positive expression of MMP-7 in submucosal SIG was significantly higher than that of mucosal SIG (P < 0.01). In contrast, MMP-7 expression was frequently found in mucosal non-SIG, suggesting an apparent difference in the invasiveness between mucosal SIG and non-SIG. The larger the size of the mucosal SIG, the more frequently MMP-7 positive expression was demonstrated (P < 0.05). There was a significant correlation between MMP-7 positive expression and lymph node metastasis of early SIG (P < 0.05). CONCLUSION: Early SIG revealed less invasiveness than non-SIG in terms of clinicopathologic features and MMP-7 expression. Preoperative estimation of the MMP-7 expression might be useful as a predictor of submucosal invasion and lymph node metastasis in early SIG.

Prognostic significance of combined expression of MUC1 and adhesion molecules in advanced gastric cancer.

The objective of the present study was to evaluate the combination of MUC1 and the status of adhesion molecules in advanced gastric cancers as a possible predictor of patient survival. Two hundred and two paraffin-embedded specimens of gastric carcinoma were examined by immunohistochemical staining using monoclonal antibodies against MUC1 mucin, E-cadherin and beta-catenin. The expression of MUC1 was considered positive if at least 10% of the neoplastic cells were stained. E-cadherin and beta-catenin were classified into four groups. Only a membranous pattern, which was stained as strongly as normal epithelial cells, was judged as normal. The absent pattern (loss of staining), cytoplasmic pattern (cytoplasmic staining with loss of membranous expression), and heterogeneous pattern (cytoplasmic staining with preservation of membranous expression) were considered abnormal. There was a significant relationship between MUC1-positive expression and abnormal expression of E-cadherin (P=0.017). The cancer with abnormal E-cadherin expression or MUC1-positive expression increased, indicating that the cancer invasion was deep. Survival analysis of the outcome revealed that the survival time for those with abnormal E-cadherin/MUC1-positive expression was shorter than for those with other expression patterns. Multivariate analysis revealed that patients with abnormal E-cadherin/MUC1-positive expression had a poorer prognosis with significance (P<0.0001). In conclusion, abnormal E-cadherin/MUC1-positive expression pattern in advanced gastric cancer is an independent unfavorable prognostic marker.

18F-fluorodeoxyglucose positron emission tomography: useful technique for predicting malignant potential of gastrointestinal stromal tumors.

The malignant potential of gastrointestinal stromal tumors (GISTs) is difficult to diagnose before surgery because the diagnoses are based on tumor diameter and mitotic index. The progression of small GISTs is always observed because they do not seem to have malignant potential. 18F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is a useful technique for assessing tumor activity. The objective of this study was to determine if FDG-PET is useful for predicting the malignant potential of gastric GISTs. Ten patients diagnosed with gastric GISTs participated. FDG-PET was performed on all of them before tumor resection. A whole-body image was initiated 40 minutes after the injection of 275 to 370 MBq FDG. FDG uptake was assessed by a standardized uptake value. All tumors had FDG uptake. There was a significant correlation between the FDG uptake and both the Ki67 index and the mitotic index but not the tumor diameter. The FDG uptake and malignant potential of gastric GISTs had a significant correlation. FDG-PET may be of considerable value for predicting the malignant potential of gastric GISTs before surgery. A gastric GIST with a high FDG uptake should be regarded as having malignant potential.

Gastrointestinal stromal tumor of the stomach: report of a case.

We report herein a case of a 65-year-old woman who had a gastrointestinal stromal tumor (GIST) of the stomach. Preoperative endoscopic and X-ray examinations showed a spherical submucosal tumor in the gastric fornix. We resected the tumor by laparoscopic surgery, because it was detected by computed tomography (CT) and positron emission tomography (PET), and they did not detect distant metastasis. Postoperative histologic examination revealed that the tumor was composed of spindle-shaped cells with elongated nuclei and showed little mitosis. Almost all of the cells showed immunoreactivity for c-kit, CD34, vimentin and but did not show alpha-smooth muscle actin (SMA), S-100, or desmin. The Ki-67 labeling index was 0.8%. The tumor did not show differentiation toward smooth muscle or neural cells. Pathological findings showed this tumor was probably benign. In such cases, careful follow-up is needed to detect liver metastasis and local recurrence.

Postoperative functional evaluation of jejunal interposition with or without a pouch after a total gastrectomy for gastric cancer.

BACKGROUND: The objective of this study was to compare the motility of a gastric substitute after jejunal interposition without a pouch and jejunal interposition with a pouch and to evaluate the relationship of both methods with nutritional outcome. METHODS: Twelve patients with gastric cancer treated by total gastrectomy and reconstruction with jejunal interposition without a pouch (J-I) and 14 patients treated by total gastrectomy and reconstruction with jejunal interposition with a pouch (J-P) were investigated in regard to the motor activity of the interposed jejunum and changes in body weight and dietary intake. RESULTS: Phase III of the interposed jejunum without a pouch was observed over a 3-month follow-up, but phase III of the interposed jejunum with a pouch was not observed in any patient within 3 months of surgery. In the fed state, the motor activity of the interposed jejunum without a pouch increased significantly in patients within 12 months of follow-up, but in the interposed jejunum with a pouch, it did not. The amount of food consumed by the J-I group was significantly greater than that consumed by the J-P group. CONCLUSIONS: This study demonstrates that the interposed jejunum with a pouch shows marked disturbances from the motor pattern of a normal jejunum during the fasting and fed states. These motor abnormalities may be responsible for insufficient food intake of the J-P group.

Mucin phenotypic expression in early signet ring cell carcinoma of the stomach: its relationship with the clinicopathologic factors.

Gastric early-stage signet ring cell carcinoma (SIG) has been reported to have a lower rate of lymph node metastasis and a higher rate of favorable prognosis than other histological types. However, the development and progression mechanisms of early-stage SIG (early SIG) are controversial. This study examined the correlation between the mucin phenotype of early SIG and its clinicopathologic factors, particularly for the sake of less invasive surgery. Sixty-nine early SIGs were studied immunohistochemically with gastric mucin (M1 and MUC6) and intestinal mucin (MUC2). SIGs were classified into gastric (G), intestinal (I), gastrointestinal (GI), or unclassified (U) type. The intramucosal spreading patterns of SIG were investigated and then classified as either expansive or infiltrative. SIGs were classified into G-type (59.4%) and GI-type (40.6%). Neither the I- nor the U-type was observed. The GI-type expression correlated with the depth of tumor invasion in SIGs (P < 0.05). In contrast, there was no increase in GI-type expression in relation to tumor size. Intramucosal infiltrative growth correlated with intestinal metaplasia (IM) of background mucosa of SIGs (P < 0.01). There was no significant correlation between phenotypes and intramucosal spreading pattern. In conclusion, the GI-type expression of SIG is a clinically useful factor for predicting submucosal invasion. The findings of SIG surrounded with IM revealed the need to exercise great care in determining the surgical margin.

Erythromycin induces pyloric relaxation accompanied by a contraction of the gastric body after pylorus-preserving gastrectomy.

BACKGROUND: Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery; however, long-term retention of food in the residual stomach is a frequent complication during the early postoperative period. We reported that gastric stasis after PPG was attributable to the delayed recovery of gastric phase III, in which pyloric relaxation accompanied a contraction of the gastric body. The objective of the present study is to determine whether erythromycin can induce phase III with pyloric relaxation after PPG. METHODS: We studied gastrointestinal motility in dogs after PPG by using strain gauge force transducer. After randomized administration of either erythromycin or saline, interdigestive gastropyloroduodenal motility was recorded. RESULTS: Erythromycin induced phase III with pyloric relaxation in the early postoperative period. Pyloric relaxation accompanied a contraction of the gastric body. Compared with the saline group (body: 87.2 +/- 16.7 mmHg x min, antrum: 69.7 +/- 13.7 mmHg x min, pylorus: 91.7 +/- 22.1 mmHg x min), the erythromycin group showed significantly increased gastropyloric motility indexes (body: 506.2 +/- 33.5 mmHg x min, antrum: 430.9 +/- 53.7 mmHg x min, pylorus: 589.5 +/- 59.5 mmHg x min). CONCLUSIONS: Erythromycin can induce phase III, in which pyloric relaxation accompanied a contraction of the gastric body in the early postoperative period after PPG. Erythromycin might be used as a prokinetic agent for the treatment of early gastric stasis after PPG.