Evaluation of "gastric" emptying time in the J pouch compared with a standard esophagojejunal anastomosis

Quality of life in cancer survivors 5 years or more after total gastrectomy: a case-control study

INTRODUCTION

This study investigated how total gastrectomy (TG), along with memories of cancer, affect the subjective wellness of survivors long after surgery. Rational approaches for effectively improving the quality of life (QoL) of these survivors were suggested.

METHODS

Between 2008 and 2013, QoL data of gastric cancer patients who underwent a curative TG, were obtained at 5-year postoperative follow-up visits (5-year survivors) and at visits beyond 5 years (long-term survivors). The control groups for these survivor groups were constructed from volunteers who visited our health-examination center for annual medical checkups. The Korean versions of the European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and the gastric cancer specific module, the EORTC QLQ-STO22, were used to assess QoL.

RESULTS

Five-year survivors showed worse QoL compared to the control group in role functioning, social functioning, nausea/vomiting, appetite loss, financial difficulties, reflux, eating restrictions, taste, and body image, and better QoL in the emotional and cognitive functioning scales. In long-term survivors, deterioration in QoL were still apparent in financial difficulties, reflux, and eating restrictions, while QoL differences in the remaining scales had diminished.

DISCUSSION

Surviving 5 years after TG does not result in living in a carefree state in terms of QoL. After 5 postoperative years, survivors still need extended care for deteriorated QoL indicators due to symptomatic, behavioral, and financial consequences of surgery.

CONCLUSION

While relevant clinical and institutional approaches are required for corresponding declines in QoL, such efforts must extend beyond 5 postoperative years.

Usefulness of reconstruction with jejunal pouch in total gastrectomy for gastric cancer in early improvement of nutritional condition

BACKGROUND

Roux-en-Y reconstruction with a jejunal pouch is a modified standard procedure in total gastrectomy for gastric cancer. The aim of the current study was to evaluate the usefulness of the reconstruction using a jejunal pouch in subsequent improvement of the nutritional condition of patients with gastric cancer after total gastrectomy.

METHODS

Sixteen patients with gastric cancer treated by total gastrectomy and reconstruction with simple Roux-en-Y from January 1993 to December 1996 and 14 patients treated by total gastrectomy and reconstruction with Roux-en-Y and jejunal pouch from January 1997 to December 1998 were investigated in regard to postoperative heartburn, changes in the body weight, and prognostic nutritional index.

RESULTS

Postoperative heartburn occurred in 1 patient (7.1%) among patients treated with Roux-en-Y and jejunal pouch and 3 (18.8%) among patients treated with simple Roux-en-Y. The body weight ratio at 1 year after operation in patients treated with Roux-en-Y and jejunal pouch (88.2% +/- 4.2%) was significantly higher than that in patients treated with simple Roux-en-Y (80.0% +/- 4.6%; P <0.01). The prognostic nutritional index ratios for patients treated with Roux-en-Y and jejunal pouch at 1 and 3 months after operation were 93.9% +/- 9.1% and 101.7% +/- 11.0%, respectively, and were significantly higher than that in patients treated with simple Roux-en-Y (86.2% +/- 8.8% and 88.1% +/- 8.2%, P <0.05 and P <0.01, respectively).

CONCLUSIONS

Reconstruction using a jejunal pouch in total gastrectomy is useful for an early improvement of the nutritional condition of patients with gastric cancer.

Simple versus double jejunal pouch for reconstruction after total gastrectomy

BACKGROUND

Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight.

METHODS

In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein.

RESULTS

The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction.

CONCLUSIONS

Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

Symptoms after total gastrectomy on food intake, body composition, bone metabolism, and quality of life in gastric cancer patients--is reconstruction with a reservoir worthwhile?

Gastric cancer is worldwide one of the most common causes of cancer death. Operation is the only treatment at this time that cures some patients. The side effects of the operation are, however, considerable, and include postoperative weight loss, loss of appetite, and other metabolic and nutritional changes. The recovery is very slow and incomplete. Reconstruction with different types of pouches has been asserted to facilitate the nutritional recovery, but results from different studies are somewhat contradictory. Malnutrition, osteoporosis, osteomalacia, and impaired quality of life are often but not always described. We can, however, establish that after a total gastrectomy, gastric cancer patients are very much at risk for these complications, which are probably caused by impaired food intake and steathorrhea even when the patients are cured from their cancer disease. In order to minimize the nutritional problems, it is crucial to avoid anastomotic narrowing and bile reflux. Roux-en-Y reconstruction seems to be the method of choice. Evidence from several randomized studies now speak in favor of including some type of pouch in the reconstruction. The most commonly used pouch today is the jejunal J-pouch. How the effect is exerted is not clear. Probably both the reservoir function of the pouch and changes in intestinal transit time are important. The importance of nutritional surveillance of these patients should not be underestimated, and most of the observed differences from various reports are probably due to dissimilarity in the follow-up protocols. A patient surviving his/her cancer has a decreased risk of developing severe disturbances in bone metabolism, food intake, body composition, and quality of life if the patient is under concerned nutritional surveillance and reconstructed with a pouch.

A new approach to the palliation of advanced proximal gastric cancer

BACKGROUND

The operative mortality and morbidity rates of palliative total gastrectomy can be high, and survival is not extended. The quality of a foreshortened life is often marred by distressing postprandial symptoms and relentless weight loss. These problems can be attributed to the conventional manner of reconstruction after total gastrectomy, with small-bowel gastric reservoirs restricting the amount of caloric intake. Large-bowel gastric reservoirs have greater capacity and empty well if positioned upright within the chest for proper emptying. The scope of a combined palliative total gastrectomy, esophagectomy, and colon pull-through must be kept within the limits of patient tolerance.

STUDY DESIGN

A palliative total gastrectomy was performed in 70 patients with incurably advanced cancers of the proximal and middle third of the stomach (TNM stages: II, 4%; III, 26%; and IV, 70%) using the large-bowel as a gastric substitute. The trauma of reconstruction by colon pull-through was lowered by avoiding thoracotomy and by positioning the colon within the lumen of the deepithelialized esophagus. Proximal cervical esophagocolostomy, distal duodenocolostomy, and colocolostomy reestablished gastrointestinal continuity. Follow-up focused on subjective gastrointestinal symptoms and nutritional maintenance.

RESULTS

The operative mortality rate was 10%, postoperative complications were not inordinately high, and autopsy findings showed no defects in the technique of reconstruction. The normal esophageal mucosa was readily cored out through the neck and the abdomen, and the remaining esophageal muscular tunnel accommodated the pulled-through segment of colon. Quantitative assessment of postoperative quality of life proved impractical, but none of 58 longterm survivors (mean of 17.1 months for combined TNM stages II, III, and IV) suffered from disabling symptoms or pronounced weight loss. The quality of life, but not its length, appeared distinctly improved.

CONCLUSIONS

The frequently encountered problems of abdominal distress and weight loss after palliative total gastrectomy can be averted by safely positioning a colonic gastric substitute within the lumen of the normal esophagus from which the mucosal lining has been extracted.

Long term consequences of gastrectomy for patient's quality of life: the impact of reconstructive techniques

OBJECTIVE

During recent years considerable interest has been focused on quality of life as an additional therapeutic outcome measure in the surgical treatment of gastric carcinoma. However, the long term consequences of gastrectomy and the impact on quality of life of different reconstructive techniques are still a matter of controversy. To broaden the criteria for choice of treatment, we conducted a prospective randomized clinical trial to determine the impact of various gastrectomy procedures on quality of life during a 5-yr follow-up period.

METHODS

Consecutive patients (n = 64) eligible for curative gastric cancer surgery were randomized to have either total (n = 31) or subtotal (n = 13) gastrectomy or a jejunal S-shaped pouch (n = 20) as a gastric substitute after total gastrectomy. Assessments of quality of life were made on seven occasions during a 5-yr period: within 1 wk before surgery, 3 and 12 months after the surgical intervention, and then once/yr. All patients were interviewed by one of two psychiatrists, who rated their symptoms and introduced standardized self-report questionnaires covering both general and specific aspects of life. The raters were blinded for the patients' group affiliations.

RESULTS

Survival rates were similar in all treatment groups. Patients who had a total gastrectomy continued to suffer from alimentary symptoms, especially indigestion and diarrhea, during the entire follow-up period. However, patients who underwent subtotal gastrectomy had a significantly better outcome already during the first postoperative yr. Patients given a gastric substitute after gastrectomy improved with the passage of time and had an even better outcome in the long run.

CONCLUSIONS

To optimize the rehabilitation after gastrectomy, patients' quality of life must be taken into consideration. When subtotal gastrectomy is clinically feasible, this procedure has advantages in the early postoperative period. However, a pouch reconstruction after total gastrectomy should be considered in patients having a favorable tumor status suggesting a fair chance of long term survival.

Long-term beneficial effects of a gastric reservoir on weight control after total gastrectomy: a study of potential mechanisms

BACKGROUND

Weight loss after total gastrectomy is a regular occurrence. Reconstruction with a gastric substitute has been suggested to facilitate recovery, but few randomized studies are available.

METHODS

In a randomized study comparing subtotal, total and total gastrectomy with an S-shaped pouch, 36 patients who had total gastrectomy with or without a pouch survived for more than 3 (mean 5.2) years. Body composition (four-chamber model, dual-energy X-ray absorptiometry, anthropometric data) was evaluated before operation, after 12 months and at long-term follow-up. Food intake was registered as a 4-day food record at 12 months and at long-term follow-up.

RESULTS

At long-term follow-up those allocated to the gastric substitute arm had lesser degrees of weight loss consisting mainly of the depletion of body fat stores, whereas lean body mass showed no significant decrease when adjusted for the process of ageing. There was no significant difference in food intake.

CONCLUSION

Reconstruction with an S-shaped gastric substitute facilitates long-term recovery after total gastrectomy and should be considered when the prognosis is favourable.

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.

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.

Reconstruction of the food passage after total gastrectomy: randomized trial

Controversial results have been reported regarding the importance of the duodenal food passage after total gastrectomy. There are a number of experimental and clinical studies showing an advantage for the jejunal interposition between esophagus and duodenum. Others favor the Roux-en-Y reconstruction, as it is technically less demanding. The purpose of this study was the randomized comparison between two major reconstruction principles after total gastrectomy for gastric cancer (i.e., jejunal interposition with pouch versus Roux-en-Y pouch reconstruction). A group of 120 patients with gastric cancer were randomized and operated on during a 5-year period according to standardized operative protocols, using either a jejunal interposition with pouch (JIP) or the Roux-en-Y reconstruction with pouch (RYP). Endpoints of this study were operation time, intra- and postoperative problems and complications, patients' body weight, functional assessment, and quality of life. Of the 120 patients, 14 had to be withdrawn during the operation because only the Roux-en-Y reconstruction was technically possible. Finally, 53 patients with JIP were compared with 53 patients with RYP for the perioperative course. There were no significant differences between the two procedures (RYP and JIP) regarding complications (24.5% and 26.4%, respectively), mortality (3.8% and 1.9%, respectively), and operation time (4.35 hours and 4.40 hours, respectively). For long-term functional comparison 46 (RYP, n = 26; JIP, n = 20) patients were without recurrence after 3 years of survival. Comparison of body weight, Visick scoring, and the Spitzer Index also did not reveal any significant difference between the two operation methods.(ABSTRACT TRUNCATED AT 250 WORDS)