Is a distal jejunojejunal pouch nutritionally ideal in total gastrectomy?

Effects on the pouch of different digestive tract reconstruction modes assessed by radionuclide scintigraphy

AIM: To determine the effect of three digestive tract reconstruction procedures on pouch function, after radical surgery undertaken because of gastric cancer, as assessed by radionuclide dynamic imaging.

METHODS: As a measure of the reservoir function, with a designed diet containing technetium-99m (^99mTc), the emptying time of the gastric substitute was evaluated using a ^99mTc-labeled solid test meal. Immediately after the meal, the patient was placed in front of a γ camera in a supine position and the radioactivity was measured over the whole abdomen every minute. A frame image was obtained. The emptying sequences were recorded by the microprocessor and then stored on a computer disk. According to a computer processing system, the half-emptying actual curve and the fitting curve of food containing isotope in the detected region were depicted, and the half-emptying actual curves of the three reconstruction procedures were directly compared.

RESULTS: Of the three reconstruction procedures, the half-emptying time of food containing isotope in the Dual Braun type esophagojejunal anastomosis procedure (51.86 ± 6.43 min) was far closer to normal, significantly better than that of the proximal gastrectomy orthotopic reconstruction (30.07 ± 15.77 min, P = 0.002) and P type esophagojejunal anastomosis (27.88 ± 6.07 min, P = 0.001) methods. The half-emptying actual curve and fitting curves for the Dual Braun type esophagojejunal anastomosis were fairly similar while those of the proximal gastrectomy orthotopic reconstruction and P type esophagojejunal anastomosis were obviously separated, which indicated bad food conservation in the reconstructed pouches.

CONCLUSION: Dual Braun type esophagojejunal anastomosis is the most useful of the three procedures for improving food accommodation in patients with a pouch and can retard evacuation of solid food from the reconstructed pouch.

Comparing aboral versus oral pouch with preserved duodenal passage after total gastrectomy: does the position of the gastric substitute reservoir count?

BACKGROUND

Total gastrectomy results in a significant weight loss, different postgastrectomy symptoms, and a reduction in quality of life. Elaborate surgical reconstruction methods are evaluated to improve results. The present study compares two types of reconstructions--an aboral pouch with preserved duodenal passage and an oral pouch with preserved duodenal passage--differing only in the site of the pouch.

METHODS

Twenty-eight patients entered the study. Primary outcome measures--body weight, body mass index, and quality of life, and secondary outcome measures--serum nutritional parameters, scintigraphic small-intestinal passage, and lipid and carbohydrate absorption were measured 6, 12, and 24 months after surgery.

RESULTS

No significant differences were found in anthropometric parameters or in quality of life between the groups. Regarding the secondary outcome measures, albumin levels were higher in the oral pouch group, while protein and immunoglobulin-A levels were higher in the aboral pouch group.

CONCLUSION

The site of the reservoir does not significantly influence the outcome after total gastrectomy and reconstruction with a preserved duodenal passage.

Comparative study on three types of alimentary reconstruction after total gastrectomy

BACKGROUND

More than 70 alimentary reconstruction procedures after total gastrectomy have been proposed to reduce the postoperative syndromes such as dumping syndrome, reflux esophagitis, and malnutrition. However, the optimal alimentary reconstruction method is still a matter of debate. The aim of the current study was to investigate the rationality of different alimentary tract reconstruction methods after total gastrectomy for gastric malignancy.

METHODS

Three types of digestive reconstruction methods were performed after total gastrectomy in 285 cases of gastric malignancy from May 1996 to December 2006, including Orr-type Roux-en-Y reconstruction (Orr-type), P-type Roux-en-Y reconstruction (P-type), and Moynihan-type reconstruction (Moynihan-type) methods. The operative time, early postoperative complications and mortality, food intake, alimentary symptoms, Visick scores, nutritional status at 1 and 3years after surgery, and cumulative survival at 1, 3, and 5years were comparatively analyzed.

RESULTS

There were no significant differences among the three methods in early postoperative complications and mortality, postoperative food intake and nutritional status (hemoglobin, total proteins and albumin), and incidence of diarrhea and dumping syndrome at 1 and 3years (p > 0.05). The overall 1-, 3-, and 5-year cumulative survival rate were 75.30%, 39.86%, and 21.48%, respectively, without significant differences among the three groups (p > 0.05). However, the average operative time used in the Orr-type reconstruction method (2.9 +/- 0.1h) was comparatively shorter than that used in the P-type (3.4 +/- 0.2h) and the Moynihan-type (3.2 +/- 0.1h). The incidences of reflux esophagitis after the gastric reconstruction with the Moynihan-type method at 1 and 3years (72% and 65%) were significantly higher than that with the Orr-type (3% and 0%) and P-type (5% and 0%; p < 0.01). Constituent ratio of Visick scores I-II of the Moynihan-type method at 1 and 3years (54% and 73%) were smaller than that of the Orr-type (94% and 96%) and the P-type (93% and 96%) methods (p < 0.01).

CONCLUSION

Orr-type Roux-en-Y reconstruction method can avoid reflux esophagitis, and the procedure is simpler than the other two methods. Therefore, Orr-type Roux-en-Y reconstruction can be recommended as an adoptable method of digestive reconstruction after total gastrectomy for gastric cancer.