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PubMed1989

Cost-benefit of follow-up after total gastrectomy.

An appraisal in terms of cost/benefit or follow-up gastrectomy for gastric cancer is made. Between 1981 and 1987, 90 patients underwent surgery (resectability 94%); of the radically treated patients, 32 underwent total gastrectomy (55%) and 26 subtotal resection (44%). In the group of 32 patients receiving palliative treatment, 11 underwent total gastrectomy. Two patients (4.6% died postoperatively of pulmonary complications and hyperosmolar coma during TPN. Instrumental, clinical and laboratory follow-up was performed in 82 patients out of 88 (93%), 6 not being available for outpatient follow-up. Our standard follow-up examination in these patients includes the following studies (chest x-ray, EGD, liver ultrasound, upper abdominal CT scan, cholescintigraphy with HIDA and barium examination of the upper G.I., tract when needed) performed every 6 months for the first 2 years and then annually for the next 5 years. Laboratory tests were performed every 3 months for the first 2 years and then every 12 months in order to monitor both evolution of neoplasia and possible metabolic functional problems. In the group of patients who underwent total radical gastrectomy, no side-effects or dysfunctional problems were observed, and the recovery of body weight was never less than 80% of the weight prior to diagnosis of the disease. Until now, 4 deaths due to neoplasia have occurred, 2 of which following recurrences after total gastrectomy for peritoneal carcinosis and multiple liver metastases, with an average survival time of 21 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

[Digestive tract tumors after gastrectomy of peptic ulcer].

In a series of 160 patients submitted to esophageal resection because of cancer, four cases were found who have been partially gastrectomized for benign stomach or duodenal ulcer decades ago (2.5%). An other similar case was detected by endoscopy and aimed biopsy. In the sixth patient, the cancer developed simultaneously in the gastric remnant and in the distal jejunum loop after partial gastrectomy of Billroth--II. type. Two esophageal cancers of the above-mentioned four resected specimens, were in the T1 stage according to TNM classification of UICC. One tumour of the later two esophageal carcinomas did not reveal any clinical sign. The patient had at the same time early invasive cancer in the gallbladder and synchronously a renal cell carcinoma in the left kidney. The main clinical symptoms of the last patient could be attributed to the gallstone disease. The esophageal carcinomas that developed after partial gastrectomy did not show any difference neither in localization, in the macro- or in the microscopical features nor in the chronic esophagitis and epithelial dysplasia in comparison with other esophageal cancer of patients who were not submitted to partial gastrectomy. Attention must be called to the significance of reflux-esophagitis which can occur with partial gastrectomy. The follow-up of such patients is doubly important if the forceps biopsy detected epithelial dysplasia in the esophagus. On the other hand, the reconstruction of HIS-angle during partial gastrectomy is very important in the prevention of reflux-esophagitis.

Esophageal Neoplasms↗
PubMed1989

[Canine intestinal myoelectric activity after total gastrectomy with jejunal interposition].

Changes of intestinal myoelectric activities after total gastrectomy with jejunal interposition were studied in three conscious dogs. Under general anesthesia a total gastrectomy was performed and intestinal continuity was reestablished by a 15 cm jejunal segment interposed between the esophagus and the duodenum. Two electrodes were sown each to the serosal surface of the interposed segment of the jejunum, duodenum, and distal potion of the jejunum, respectively. After recovery from the surgery, the myoelectric activities were recorded for 8 to 12 hours during fasting and after feeding a 200 ml liquid meal. In each segment, total gastrectomy did not alter the initiation of the migrating myoelectric complex (MMC) during fasting. Total gastrectomy also changed neither the postprandial inhibition of the enteric MMC nor the induction of the fed myoelectric pattern after feeding. The way of MMC propagation along the small intestine, however, showed various patterns. Each of three segments generated its own MMCs. Some complexes migrated to the next segment or had an effect on initiating new MMCs of the next segment. Although MMCs occurring in the segment of the interposed jejunum hardly migrated to the adjacent duodenum, some jumped to the distal jejunum. These results suggest that there are no coordinated activities between the interposed jejunum and the duodenum after total gastrectomy with jejunal interposition.

Animals↗
PubMed1986

Esophageal cancer developed after gastrectomy.

Between 1965 and 1983 we treated 129 patients with primary esophageal squamous cell carcinoma. Of these patients, 12 (9.3%) had previously undergone partial gastrectomy and six manifested tumors in the lower thoracic esophagus. Esophagitis of the noncancerous esophageal mucosa surrounding the cancer was confirmed in three of five patients who underwent esophagectomy. We also retrospectively evaluated 130 patients with esophageal cancer who had undergone gastrectomy, including our 12 patients, reported in the Japanese literature between the same period. Between patients with esophageal cancer who had undergone gastrectomy and those who had not there was no age difference; there were more men in the first group. Cancer developed in the lower thoracic esophagus with relatively high frequency in patients who had undergone gastrectomy compared with those who had not. The possibility of an association between gastrectomy and the subsequent development of esophageal cancer, especially lower thoracic esophageal cancer, cannot be ruled out. Further studies are necessary to clarify a possible association.

Adult↗
PubMed1982

Serum pancreatic polypeptide responses to food and secretion in patients with Billroth I and Billroth II gastrectomies and in normal subjects.

Serum pancreatic polypeptide (PP) responses to food and to secretion were measured in 7 patients with antrectomy and gastroduodenostomy (Billroth I gastrectomy), 11 patients with antretectomy and gastrojejunostomy (Billroth II gastrectomy), and 12 normal subjects. The integrated postprandial serum PP secretion was significantly lower in the patients with Billroth II gastrectomy (4.4 +/- 0.9 nmol/L X 120 min) than in the patients with Billroth I gastrectomy (9.3 +/- 2.3 nmol/l X 120 min; P less than 0.05) and the normal subjects (10.9 +/- 1.3 nmol/L X 120 min; P less than 0.001). The serum PP response to food in the patients with Billroth I gastrectomy was not significantly different from the response in the normal subjects. The serum PP responses to intravenous injection of 1 CU/kg of secretin GIH were similar in the three groups studied. These studies point to an important role of the duodenum in the postprandial secretion of PP.

Adult↗
PubMed1994

Results of curative gastrectomy for carcinoma.

BACKGROUND: In the western literature, controversy exists regarding the operative management of carcinoma of the stomach. Still debated are the extent of gastric resection, the role of splenectomy, and the significance of lymphadenectomy. STUDY DESIGN: We performed a retrospective study of 646 consecutive patients who underwent curative gastrectomy for carcinoma of the stomach from 1950 to 1989. A multivariate analysis of nine clinicopathologic and treatment-related variables, including type of gastrectomy, splenectomy, and extent of lymphadenectomy was done to assess the relative influence of these variables on survival. RESULTS: The following variables emerged as independent predictors of death: serosal involvement, distant lymph node metastases, and total gastrectomy. Splenectomy and lymphadenectomy were not related to prognosis. However, a separate analysis on defined subsets of patients revealed that radical lymphadenectomy (removal of N2 nodes) provided a survival benefit in patients with T1-2 N0-1 disease. CONCLUSIONS: These findings suggest that although prognosis of carcinoma of the stomach is mainly determined by the stage of disease at time of operation, the choice of the surgeon can affect survival. Total gastrectomy should be avoided when it is not necessary for proximal tumor location. Subtotal gastrectomy in distally located tumors seems to be the best option. Radical lymph node dissection should be performed when nodal involvement is expected to be limited or absent.

Adult↗
PubMedDate not supplied

[Total gastrectomy and viscerosynthesis].

A retrospective study of 134 total gastrectomies performed between 1982 and 1992 was conducted with regular follow-up. There were 96 males and 38 women (mean age 66.66 years, range 27-82). The indication for total gastrectomy was malignant tumour (n = 115), mostly adenocarcinoma (79.1%, 91/115) with 7 cases of stump degeneration after partial gastrectomy (5.2%) and benign lesions (n = 19), mostly gastric ulcers. Gastrectomy was associated with node dissection in 53 cancer cases (47.8% 53/115) and dissection of neighbouring organs in 16 patients. Y anastomosis with circular mechanical suture was performed in 78 cases (62.9%) with pre-stapling in 30 (38.5%). Operative mortality was 8.2% (11/134). The oesophagealjejunal disunion occurred in 7/133 patients (5.3%) including two fatal cases. Early reoperation was necessary in 10.5%. Long-term follow-up for 2 to 12 years in 119 patients gave the following data. For malignant tumours: 5-year survival rate 10.1% (n = 8), recurrence an anastomosis 6.3% (n = 5), distant recurrence 28.2% (n = 21). For all patients sequellae were: reflux oesophagitis 8.1% (n = 10), stenosis of the anastomosis 7.3% (n = 9) requiring late reoperation in 2. The quality of life was considered satisfactory by 28.57% (n = 8) and good in 39.29% (n = 11). These results were compared with those reported in the literature and led to the conclusion that the general view as to the gravity of gastrectomy should be reconsidered in light of the progress in viscerostapling.

Adenocarcinoma↗
PubMed1996

[Surgical treatment of esophageal cancer in four patients after gastrectomy for gastric cancer].

The incidence of another cancer in subjects with esophageal cancer is high. Gastric cancer is the most common. We report surgical treatment for esophageal cancer in four patients who underwent gastrectomy for gastric cancer earlier. Extended lymphadenectomy of the neck, mediastinum, and abdomen was performed together with subtotal esophagectomy for three patients with thoracic esophageal cancer. In the two patients who had undergone subtotal gastrectomy and Billroth II reconstruction, the esophagus was reconstructed with part of the colon from the left side, perifused by the left colic artery. In a third patient, who had undergone total gastrectomy and jejunal interposition, reconstruction was done with part of the colon from the right side. In the remaining patient, who had cervical esophageal cancer and who had undergone total gastrectomy, cervical esophagectomy and total laryngectomy were done, followed by free jejunal interposition. One patient with thoracic esophageal cancer died of pulmonary metastasis of the esophageal cancer 24 months after surgery. The three other patients were not found to have recurrence in the most recent follow-up. Esophagectomy and reconstruction are more risky and complicated in patients who have already undergone gastrectomy for malignancy. However, in patients who have undergone curative surgery for gastric cancer, curative treatment for esophageal cancer such as esophagectomy together with extended lymphadenectomy is indicated.

Aged↗
PubMedDate not supplied

Gallstones and gallbladder disorder after gastrectomy for gastric cancer.

The incidence of gallbladder diseases, in particular of gallstones, was investigated in 268 cases during follow-up after resection of a gastric cancer. Factors investigated for correlation with any incidence included the extent of gastrectomy, reconstruction, and the degree of lymph node dissection. Moreover, in 20 of these, the contractile function test using a cerulein injection was performed, while in a further 6 cases, a sequential contractile function test with fatty meal was performed. The incidence of gallstones was 10.5% after total gastrectomy, 12.4% after distal gastrectomy. Debris was found in a further 6.7% after total gastrectomy and in 1.2% after distal gastrectomy. There was no difference in the incidence of gallstones among the reconstruction methods. With respect to lymph node dissection, the incidence of gallstone formation was 16.3% after D3 and 8.5% after D2-1. In the contractile function test, although the basal area was significantly larger after D3 than after D2-1, there was no difference in the contractile rate. The sequential contractile function test showed a peak contraction at 15 minutes after feeding with gradual refilling in both those after D3 and those after D2-1.

Case-Control Studies↗
PubMed1996

Long-term survival after gastrectomy for advanced bleeding or perforated gastric carcinoma.

OBJECTIVE: To find out whether massive bleeding or free perforation of advanced gastric carcinoma affect long term survival after gastrectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Teaching hospital, Hong Kong. INTERVENTIONS: Gastrectomy. MAIN OUTCOME MEASURES: Long term survival. RESULTS: Data of 50 patients with gastric carcinoma that had penetrated the serosa (pT3) and who were operated on between 1985 and 1990 were analysed. A total of 17 patients with tumour free perforation and 10 with massive bleeding underwent emergency gastrectomy, and 23 patients with comparable uncomplicated tumours had elective gastrectomy. Twelve variables that could have influenced survival including malignant perforation, bleeding, or the absence of complications were analysed using the Cox's proportional hazards model. Survival was influenced only by proliferative cell nuclear antigen (PCNA) index and not by perforation, bleeding, or the uncomplicated nature of the tumour. CONCLUSIONS: These findings suggest that perforation or bleeding from advanced gastric carcinomas do not significantly affect long term survival after gastrectomy.

Aged↗
PubMed1996

[Postoperative fistulas after gastrectomy: risk factors in relation to incidence and mortality].

The relations between incidence and prognosis of postoperative fistulas after gastrectomy and some different variables were analysed in the present retrospective study. Thirteen digestive fistulas of 113 patients (11.9%) submitted to gastrectomy during the period 1989-1994 represent the study population. The incidence of postoperative fistulas was compared to the kind of gastric pathology, to the extension of gastrectomy, to different nutritional (serum haemoglobin, albumin and transferrin level, weight loss) and immunological factors (serum lymphocytes) and, for oncological patients, to the stage of the disease. Incidence was directly related to the extension of gastrectomy, to serum albumin and haemoglobin level, and to weight loss rate. The results were not statistically significant at Kruskal-Wallis and ANOVA tests. No relation was found between incidence of fistulas and serum transferrin level, number of lymphocytes and adoption of early postoperative enteral nutrition. Six patients had spontaneous closure of the fistula with conservative therapy. Seven patients required reoperation because of abdominal sepsis (53.8%). Three patients died (23%). Although spontaneous closure, reoperation and mortality were related to nutritional and immunological state, no examined variables showed a statistically significative relation. The adoption of early postoperative enteral nutrition was not related to the prognosis, unlike the stage of the disease: patients submitted to reoperation had a TNM III or IV stage; dead patients had a TNM IV stage. Treatment of metabolic-nutritional unbalance can prevent anastomotic failure and fistula after gastrectomy and improve the prognosis. The relation between early postoperative enteral nutrition and incidence and prognosis of postoperative fistulas remains unclear.

Analysis of Variance↗
PubMedDate not supplied

Quality-of-life after curative surgery for gastric cancer: a comparison between total gastrectomy and subtotal gastric resection.

BACKGROUND/AIMS: Quality-of-Life has become an increasingly important factor for long term survivors after surgery for gastric cancer. Quality-of Life also includes social and psychological aspects. Many gastric carcinomas are located in the distal two thirds of the stomach. In these cases, a subtotal gastric resection may be adequate if a proximal safety margin of 5 cm in intestinal type tumors according to Laurén and 10 cm in diffuse type cancers respectively can be achieved. On the other hand total gastrectomy "de principe" has been advocated for all gastric malignancies because of high local recurrence rates after subtotal resection. The aim of the present study was to assess the Quality-of-Life in long term survivors after resection for gastric cancer comparing subtotal gastric resection with total gastrectomy. METHODOLOGY: One hundred ninety-five patients were examined with the Gastrointestinal Quality-of-Life-Index (GLQI). Hard clinical data such as postoperative weight loss, frequency of daily meals and bowel emptying were evaluated. One hundred five patients were submitted for total gastrectomy and in 90 patients a subtotal gastric resection was performed. None of the patients had clinical, radiological or endoscopic evidence of recurrence. RESULTS: After subtotal gastric resection, patients achieved statistically significant better scores concerning disease/therapy-related symptoms, physical functions resulting in a better overall score (p < 0.02). Following subtotal resection, patients had a significantly lower weight loss compared to patients after total gastrectomy (p < 0.02), a smaller number of daily meals (p < 0.001) and a lower frequency of bowel emptying/day (p = 0.031). There was no statistically significant difference in emotional status or social activities showing a similar acceptance of disease and therapy in both groups. CONCLUSIONS: In those cases where an adequate proximal safety margin can be achieved by a subtotal gastric resection, this procedure is preferable to a total gastrectomy. However preservation of the gastric stump should never be allowed to compromise oncological radicality.

Adult↗
PubMed1997

Reflux esophagitis after proximal subtotal gastrectomy.

BACKGROUND: Carcinoma of the cardia of stomach or carcinoma of the esophagocardiac (EC) junction has a poor prognosis. Proximal subtotal gastrectomy is often performed for a smaller tumor. It achieves a prognosis similar to that of total gastrectomy and prevents pernicious anemia. A better functional result was expected than that total gastrectomy did from us, but the clinical observation was surprising. Most patients had symptoms of reflux esophagitis after surgery. All of these patients were reevaluated. METHODS: From November, 1990 to March, 1996, there were 27 patients who received proximal subtotal gastrectomy at this hospital. Twenty of these were involved in this study. Floppy Nissen's fundoplication was performed during operation as a anti-reflux procedure. Continuous 24-h pH monitoring, esophageal manometry, and endoscopic examination were performed for study. RESULTS: Most of the patients had symptoms of gastroesophageal reflux. 80% (16/20) of the patients were found to have reflux esophagitis under endoscopy. The patients had higher pH scores (mean 85.8 +/- 45.6) than normal (< 17.5), lower pressure of LES (8.03 +/- 7.01 mmHg), shorter total lengths (mean 1.60 +/- 0.56 cm) and intraabdominal lengths (mean 1.29 +/- 0.30 cm) of new lower esophageal sphincters. CONCLUSIONS: Clearly there was failure to prevent reflux esophagitis through floppy Nissen's fundoplication. Severe gastroesophageal reflux did appear after proximal gastric resection. A gastric remnant with safe cut-margin is often too short to perform complete wrapping. Proximal subtotal gastrectomy is not recommended for early cancer of the cardia of the stomach.

Aged↗
PubMed1997

The influence of partial gastrectomy on the ultrastructural changes in the liver--an experimental animal model.

The aim of our studies was to evaluate the ultrastructural changes in the liver in rats after partial gastrectomy. The studied group consisted of 19 Wistar strain rats. In 15 animals partial gastrectomy was done. The control group underwent laparotomy, only. All tissue material was fixed and then prepared in a routinous way for histological and electron microscopy studies. During histological examinations no abnormalities were found. On the ultrastructural level (in tissue samples taken from animals, no more then 4 months after gastrectomy) we found mitochondrial degeneration, vacuolization of cytoplasm, abnormalities in the nuclei and increased activity of B-K cells. The focal necrosis of the hepatocytes was also observed. In tissue samples from animals after 4 to 12 months after primary operation we found increasing number and size of lipid vacuoles in the cytoplasm of hepatocytes The number of Ito cells increased, also. The gastrectomy caused only minimal ultrastructural changes in the liver tissue within the period of observation. Those changes described above may result from numerous metabolic derangements found after gastrectomy.

Animals↗
PubMedDate not supplied

Complete omentectomy and extensive lymphadenectomy with gastrectomy improves the survival of gastric cancer patients with metastases in the adjacent peritoneum.

BACKGROUND/AIMS: The omentum is the site where peritoneal metastases occur most frequently. It has not been shown whether complete resection of the omenta during gastrectomy improves the survival of gastric cancer patients with macroscopic peritoneal metastases. METHODOLOGY: We retrospectively analyzed 126 patients who underwent gastrectomies for gastric cancer with peritoneal metastases but without hematogenous metastases. The 126 patients were stratified according to their grade of peritoneal metastases into three groups: the P1 patients (patients with peritoneal metastases in the adjacent peritoneum but not in the distant peritoneum); the P2 patients (patients with a few peritoneal metastases in the distant peritoneum); and the P3 patients (patients with many metastases in the distant peritoneum). In each group, the survival and clinicopathological characteristics were compared between patients treated by complete resection of the greater omentum and the lesser omentum plus extensive lymphadenectomy during gastrectomy, versus patients treated by incomplete resection of the omenta and non-extensive lymphadenectomy during gastrectomy. RESULTS: Complete omentectomy and extensive lymphadenectomy during gastrectomy improved survival significantly only in the P1 patients. Other clinicopathological characteristics did not differ between them. CONCLUSION: Complete omentectomy and extensive lymphadenectomy is recommended in patients with peritoneal metastases in the adjacent peritoneum but not in the distant peritoneum.

Adenocarcinoma↗
PubMed1976

Gastric acid and serum gastrin responses to insulin and 2-deoxy-d-glucose in duodenal ulcer patients before and after partial gastrectomy.

Gastric acid and serum gastrin (radioimmunoassay) responses to insulin (0.2 U/kg i.v.) and 2-deoxy-D-glucose (2DG) (50 mg/kg i.v.) were determined in 11 male duodenal ulcer patients before and after partial gastrectomy involving complete antral resection. In 8 of the patients the acid response to pentagastrin (6 mug/kg subc.) was also determined. Before operation, 2DG produced higher acid and gastrin responses than insulin. Partial gastrectomy reduced basal acid secretion by 54% but did not alter the basal gastrin level, suggesting that this gastrin is of extra-antral origin. Partial gastrectomy reduced the acid responses to insulin and 2DG by 66% and 78%, respectively; after operation the acid responses to these stimulants were equal. The ratio for the acid response to insulin and pentagastrin was 65% before and 56% after partial gastrectomy; corresponding ratios for 2DG and pentagastrin were 112% and 48%. Partial gastrectomy abolished the peak gastrin response to insulin hypoglycemia and reduced that to 2DG by 64%. The integrated gastrin response to insulin and 2DG was insignificant in the operated patients. Both insulin and 2DG release mainly antral gastrin which appears to be of greater importance for the acid response to 2DG than insulin.

Adult↗
PubMed1997

High prevalence of bone disorders after gastrectomy.

BACKGROUND: Studies indicate that gastrectomy might alter calcium and bone metabolism, resulting in bone disorders. No data are currently available on the prevalence of bone disorders after gastrectomy. METHODS: Sixty gastrectomy patients were investigated for serum parameters of calcium and bone metabolism 5 to 20 years postoperatively and compared to an age- and sex-matched healthy control population. Forty patients agreed to a radiological investigation of the spine by anterior-posterior and lateral radiographs of the thoracic and lumbar spine and by computed tomography (CT) osteodensitometry. RESULTS: Serum calcium and 25-(OH)-vitamin D were decreased in gastrectomized patients, while parathyroid hormone and 1,25-(OH)2-vitamin D were increased. Serum parameters of calcium metabolism were altered in as many as 68% of patients. We found 31 vertebral fractures in 13 patients, 30 grade 2 vertebral deformities in 18 patients, and osteopenia in 15 patients, corresponding to a prevalence of 33%, 45%, and 37% in gastrectomized patients, respectively. The overall rate of gastrectomy patients having vertebral fractures and/or osteopenia was 55%. The risk of having a vertebral deformity was increased by more than sixfold after gastrectomy. Our study is the first report evaluating vertebral deformities in gastrectomized patients, and the largest series of gastrectomized patients investigated by CT osteodensitometry. CONCLUSION: We found a high prevalence of bone disorders in gastrectomized patients, possibly resulting from disorders in calcium metabolism. Postgastrectomy bone disease might derive from a calcium deficit, which increases calcium release from bone and impairs calcification of newly build bone matrix.

Absorptiometry, Photon↗
PubMedDate not supplied

Cholelithiasis and cholecystitis after gastrectomy for gastric carcinoma: a comparison of lymphadenectomy of varying extent.

BACKGROUND/AIMS: The complications of cholelithiasis and cholecystitis after gastrectomy for gastric carcinoma were reviewed. PATIENTS AND METHODS: Between 1983 and 1988, 474 patients with a normal gallbladder received gastrectomy for gastric cancer. RESULTS: Among the 288 patients who underwent radical gastrectomy with systematic lymphadenectomy (RG), 9 (3.1%) were suffering from acute postoperative acalculous cholecystitis, and 2 of them died. None of the 186 patients treated with simple gastrectomy (SG) developed this complication (RG vs. SG, p <0.05). The long-term prognosis of RG is better than that of SG. However, as of July 1993, of among the 463 patients with a normal gallbladder who survived the operation, 85 of the 281 patients who underwent RG and 9 of the 182 patients who underwent SG had gallstones (RG vs. SG, P<0.001). Of the cases complicated by postgastrectomy cholelithiasis, the mean interval between gastrectomy and gallstone formation was shorter in the RG patients (31.4 +/- 20.9 months) than in the SG patients (48.0 +/- 12.8 months) (P<0.05). Following gallstone formation, there was a higher rate of acute biliary symptoms in patients who underwent RG. CONCLUSIONS: Early cholecystectomy should be performed in patients who received an RG with gallstone formation. Moreover, it would be better to include a policy of prophylactic cholecystectomy in the procedures of RG, even if the gallbladder is normal, in order to prevent the complications of acute cholecystitis and cholelithiasis.

Acute Disease↗