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PubMed1996

Gastric remnant carcinoma after partial gastrectomy for benign and malignant gastric lesions.

BACKGROUND: A retrospective study was designed to evaluate the clinicopathologic characteristics and prognosis of gastric stump carcinoma (GSC) after gastrectomy for gastric adenocarcinoma. STUDY DESIGN: A comparison of the clinicopathologic features was made between 12 cases of GSC and 27 cases of remnant carcinoma (RC) following gastrectomy for adenocarcinoma. The various factors influencing survival of both groups of patients were evaluated separately and by multivariate analysis. RESULTS: Gastric stump carcinoma emerges late after initial gastrectomy and has a significant tendency toward lymph node metastasis. No difference was observed between the survival curves for patients with GSC or RC after gastrectomy for malignancy. Serosal invasion was the factor most affecting survival. CONCLUSIONS: Early diagnosis is most important for management of the disease, and only patients with T2 staged GSC according to the Union Internationale Contre le Cancer classification system might benefit from extensive lymphadenectomies.

Adenocarcinoma↗
PubMed1995

Laparoscopic and minilaparotomy proximal gastrectomy and esophagogastrostomy: technique and case report.

A laparoscopic and minilaparotomy proximal gastrectomy with esophagogastrostomy (end-to-side anastomosis) was performed on a 56-year-old woman with a leiomyoma located just below the esophagogastric junction. Gastroscopic examination revealed a leiomyoma (diameter of 2.5 cm) just below the esophagogastric junction. We considered a laparoscopic proximal gastrectomy safer than a laparoscopic partial gastrectomy because of the risk of postoperative anastomotic stenosis in this case. Therefore, the patient underwent laparoscopic minilaparotomy proximal gastrectomy with esophagogastrostomy. On postoperative day 1, she was able to walk. On postoperative day 4, she started on a clear liquid diet and was discharged on postoperative day 14. During her postoperative recovery, the patient experienced little pain and did not request narcotic analgesia.

Anastomosis, Surgical↗
PubMed1996

[Is splenectomy "en principe" necessary for radical gastrectomy with systematic lymphadenectomy?].

SUMMARY: In order to screen the necessity of splenectomy "en principe" we evaluated all patients suffering from gastric carcinoma between Jan. 1988--Apr. 1993 retrospectively. In total a group of 318 patients were treated and from these 261 patients were operated (resection rate 82%). In 30% of the patients (77 pat.) we performed a subtotal distal gastrectomy and in 70% (184 pat.) a radical gastrectomy with a D 2-lymphadenectomy. The splenectomy rate in the group of gastrectomy was 94% (173 pat.). In total 13% of the lymph nodes of the hilus of the spleen were infiltrated and an additional metastasis of the spleen was found in 1%. In carcinomas located at the minor curvature 13% had an infiltration of the lymph node station 10, in carcinomas located at the greater curvature in 17% and in carcinomas with a diffuse tumor growth in 10% respectively. Patients with a tumor located in the proximal stomach had an infiltration of the lymph nodes in 14% and in carcinomas of the antrum in 7% respectively. None of the patients having a UICC stage I/II had an infiltration of the lymph nodes at the hilus of the spleen, but 25% of the patients having a UICC stage III/IV. 2 patients from the latter group had an additional metastasis of the spleen. CONCLUSION: The indication of splenectomy is given only in advanced proximal tumor locations, especially in tumors of the greater curvature. In the early tumor stages and in the distal locations of gastric carcinoma it might be useful to perform a selective lymph node dissection of the hilus of the spleen in order to increase the completeness of the radical gastrectomy.

Gastrectomy↗
PubMed1996

[Extent of radical surgery in cardia carcinoma--esophagectomy or gastrectomy?].

In patients with cardia cancer, showing a tumor center between 1 cm above to 2 cm below the anatomical cardia, the results of transhiatal esophagectomy with proximal gastrectomy versus total extended gastrectomy with distal esophageal resection were compared. For gastrectomy, postoperative mortality was significantly lower (2% vs. 8.6%), whereas the rates of R0 resection (81% vs. 68%) and 5-year survival rate (48 vs. 25%) were significantly higher than after esophagectomy. If in cardia cancer, according to the mentioned definition, R0 resection can be achieved by extended total gastrectomy and distal esophageal resection, this represents the procedure of choice for this strictly defined type of carcinoma of the cardia.

Adenocarcinoma↗
PubMed1997

Experimental study of laparoscopic gastrectomy: intracorporeal Billroth I gastroduodenostomy.

Laparoscopic gastrectomy is now performed only for a partial resection that does not require anastomosis. We have been studying laparoscopic gastrectomy using the Billroth I method in animal models, and here we describe the surgical procedure. The gastrocolic ligament is divided along with the greater curvature, and the right gastroepiploic vessels are divided at their point of origin. The lesser omentum is dissected and the gastric antrum is divided using an endoscopic linear cutter. The anvil of a circular stapler is inserted into the duodenal bulb through the pyloric ring and ligated. An instrument for creating a pursestring suture is applied to the anterior wall of the stomach, and the circular stapler is inserted into the gastric lumen. Then Billroth I gastroduodenal anastomosis is performed with the stapler. After this anastomosis, four endoscopic linear cutters are applied to divide the gastric body, and the partial gastrectomy is completed. This animal experimental study has revealed that the Billroth I gastrectomy is easy to perform using a circular stapler and several linear cutters under laparoscopic guidance.

Animals↗
PubMed1997

[Reconstruction methods for the continuous digestive tract using surgical stapling after gastrectomy with lymphadenectomy in patients undergoing surgery for stomach cancer. Personal evaluation].

From 1984 to 1994, 152 patients were operated for gastric cancer in Clinical Department of Surgical Oncology, Medical University of Lodz. Patients age ranged from 31 to 82 years (mean age-61.2). The purpose of this study was to evaluate the methods of reconstruction of gastrointestinal tract (GIT) continuity. Our material comprised patients who underwent total gastrectomy for gastric cancer. In 52 patients radical procedure--total gastrectomy--was performed, with reconstruction of gastrointestinal tract continuity. The latter part of surgery was accomplished using different methods: Roux-Y anastomosis-10 patients (19.2%); esophago-jejunal "end to side" anastomosis-8 patients (15.4%); Hunt-Lawrence-Rodino anastomosis-34(65%). During procedures staplers and VALTRAC rings were used, as well as ultrasound selector and argon coagulator for hepatic and pancreatic resections. Quality of life after gastrectomy was determined on the basis of interviews taken from patients, in whom GIT continuity was reconstructed with or without intestinal pouch creation. We also evaluated incidence and type of complications after such procedures. Perioperative mortality in our material was 7.7%. We concluded that the best results was achieved when continuity of gastrointestinal tract after total gastrectomy was reconstructed with intestinal (first loop of jejunum) pouch creation (Hunt-Lawrence procedure). This method warranted high quality of life and low incidence of complications. Staplers enables us to shorten time of procedure and to decrease the number of anastomosis leaks, so that our results of surgical treatment of patients with gastric cancer were better.

Adult↗
PubMed1997

[Wernicke's encephalopathy developed several years after total gastrectomy. Report of 2 cases].

We present here 2 cases of Wernicke's encephalopathy developed several years after total gastrectomy. Case 1. A 48-year-old male developed impaired recent memory and unsteady gait. He had undergone total gastrectomy for advanced gastric cancer 5 years previously; he had been on tegafur regimen for 4 and a half years. He had had 630 ml of beer every day for 6 months until admission. On admission, there were bilateral abducens palsy, horizontal nystagmus, gait ataxia, and areflexia. Cranial MR imaging was unremarkable. After intravenous infusion of vitamin B1, the patient improved. Case 2. A 56-year-old male developed exertional dyspnea, memory loss, and unsteady gait. He had undergone total gastrectomy for a large submucosal tumor 4 years previously; he had had 300-500 ml of sake almost every day thereafter. Examination revealed bilateral abducens palsy, severe gait ataxia, and areflexia. Chest CT scans demonstrated moderate amount of pericardial effusion. Blood vitamin B1 level was abnormally low. After administration of vitamin B1, he improved. Both patients had had alcoholic drinks; laboratory findings demonstrated no liver dysfunction. Drinking alcohol, even in relatively small quantities, could precipitate the development of Wernicke's encephalopathy in gastrectomized individuals. Our 2 cases stress the importance of supplementary vitamin B1 administration after total gastrectomy.

Gastrectomy↗
PubMed2003

Efferent loop small intestinal vitamin D receptor concentration and bone mineral density after Billroth II (Polya) gastrectomy in humans.

Animal studies have demonstrated that the highest concentration of vitamin D receptors (and greatest capacity for active calcium absorption) occurs in the proximal duodenum. By passing the duodenum following Polya/Billroth II gastrectomy could result in the development of a metabolic bone disease and low bone mineral density (BMD). We thus compared the vitamin D receptor (VDR) concentration in mucosal biopsies taken at endoscopy from two functionally corresponding areas of the small intestine: the jejunum (or efferent loop) in 21 patients with a history of Polya/Billroth II gastrectomy and the second part of the duodenum in age/sex-matched control subjects. We also measured the BMD by dual energy X-ray absorptiometry. The mean VDR concentration was not significantly different between the two groups (patients vs controls, fmol/mg protein, mean +/- SE: 34.99 +/- 2.57 vs 34.67 +/- 3.71; P = 0.22), even when subgrouped as males (36.22 +/- 3.16 vs 31.2 +/- 4.24; P = 0.351) or females (31.93 +/- 4.7 vs 43 +/- 6.76; P = 0.193). In Polya/Billroth II gastrectomy patients, the VDR concentration in the efferent loop declined with age (r = -0.78, P = 0.02). In the same group, BMD, as compared with matched controls, was significantly reduced at the lumbar spine (Z-score: patients vs controls: -1.138 vs 0.099, P = 0.01), but not at the femoral neck (Z-score: -0.69 vs 0.7, P = 0.084). There was no correlation between VDR and time since operation or BMD. These results suggest that following Polya/Billroth II gastrectomy, the functional capacity of the jejunal efferent loop in reference to VDR concentration is similar to that of the second part of the duodenum in normal subjects. Therefore, the reduced BMD in our patients, also a common finding in other studies, may not be secondary to the reduced capacity of the VDR system that facilitates the active calcium transport pathway in the proximal small intestine.

Aged↗
PubMed1999

Suppression of T-cell function in gastric cancer patients after total gastrectomy with splenectomy: implications of splenic autotransplantation.

Background. In Japan since the 1960s, patients with gastric cancer have routinely had splenectomy combined with gastrectomy to ensure that lymph node dissection is complete. However, the influence of splenectomy on long-term immunity is unclear.METHODS: Forty-nine gastric cancer patients who underwent total gastrectomy for cure with ( n = 25) and without ( n = 24) splenectomy were assessed for immunologic function, including the proportion of lymphocyte subsets, purified protein derivative from tuberculin (PPD) response, natural killer (NK) activity, and phytohemagglutinin (PHA) response.RESULTS: Peripheral T-cell mediated functions, e.g., PPD and PHA response, were significantly suppressed in patients who underwent gastrectomy with splenectomy compared with those who had gastrectomy alone. Decreased T-cell subsets (CD 3+, 4+, 8+) and increased NK cell subsets (CD 16+, 57+) were observed in patients who underwent splenectomy. Patients who did not undergo splenectomy had immunologic responses within the normal range.CONCLUSIONS: Splenectomy decreased T-cell mediated responses over the long term. As a potential means to co-rrect this T-cell dysfunction in patients with splenectomy, splenic autotransplantation should be considered in future research.

Journal Article↗
PubMed1999

Surgical results of proximal gastrectomy for early-stage gastric cancer: jejunal interposition and gastric tube reconstruction.

BACKGROUND: The frequency of tumors in the upper one-third of the stomach has been increasing. The standard operation for proximal gastric cancer has been total or proximal gastrectomy. The aim of this study was to present the pathologic and surgical results of 30 patients with early-stage proximal gastric cancer managed by proximal gastrectomy.METHODS: A consecutive series of 30 patients who underwent proximal gastrectomy for early-stage proximal gastric cancer was studied. Sixteen patients underwent jejunal interposition, while 14 underwent gastric tube reconstruction, which consisted of a direct anastomosis between the esophagus and the remnant of the tube-like stomach.RESULTS: Twenty patients (67%) had no abdominal symptoms and the lesions were detected by screening gastric fiberscopy. The tumors were mostly located along the lesser curvature (73%), were grossly depressed type (IIc) (70%), and histologically well differentiated type (63%). The depth of wall invasion was the mucosa in 12 patients, submucosa in 15, and muscularis propria in 3; lymph node metastasis was absent in 28 patients (93%). When compared with patients with jejunal interposition, patients with gastric tube reconstruction had a shorter operation time (327 vs 165 min), less blood loss (508 vs 151 g), and shorter hospital stay after operation (31 vs 17 days). Endoscopy and 24-h pH monitoring showed no evidence of reflux esophagitis, except in 1 patient with gastric tube reconstruction, and no patient died of recurrence.CONCLUSIONS: Early-stage proximal gastric cancer can be successfully treated by proximal gastrectomy. Since gastric tube reconstruction is a simple, easy, and safe procedure, proximal gastrectomy followed by gastric tube reconstruction is recommended for patients with early-stage proximal gastric cancer.

Journal Article↗
PubMed1989

Roux-Y gastrectomy for chronic gastric atony.

The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients (11 men, 29 women; age 47 +/- 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastroparesis. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades III and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.

Adult↗
PubMed1993

Biliopancreatic Diversion with a New Type of Gastrectomy.

In an attempt to improve the results of biliopancreatic diversion in the treatment of morbid obesity, two aspects of the procedure performed at Laval Hospital were modified to reduce adverse physiological consequences. The distal gastrectomy was replaced by a parietal gastrectomy which preserves vagal continuity along with the lesser curvature, and leaves intact the antro-pyloroduodenal pump. The duodenum was stapled shut and nutrients were diverted through a duodeno-ileal anastomosis. The biliopancreatic diverting intestinal limb was anastomosed to the nutrient ileal limb 100 cm proximal to the ileocaecal valve instead of 50 cm proximal to it, thus doubling the length of the common ileal absorptive segment. Weight loss after either operation was greater than 70% of initial excess weight. Following the new operation, there was a lesser prevalence of side-effects, especially loose stools and malodorous gas, a lesser degree of hypocalcemia and no hypoalbuminemia. The duodenum recanalized at the staple line in 20% of the patients who had the new operation. When data from these patients were excluded, weight loss following the new operation was greater than that seen after the old one. The prevalence of side-effects and the degree of calcium and protein malabsorption remained significantly lower. Weight loss remained satisfactory with a common limb measuring 100 cm. The parietal gastrectomy was not restrictive as shown by the failure to lose further weight when the duodenal stapled diversion failed. Weight loss was thus mainly a function of biliopancreatic diversion, but increased weight loss in the new procedure despite a doubling of the common ileal limb suggests that parietal gastrectomy contributed to weight loss. Because duodenal recanalization can be corrected surgically and now prevented, the modified biliopancreatic bypass is preferred.

Journal Article↗
PubMed1995

Biliopancreatic Diversion with a New Type of Gastrectomy: Some Previous Conclusions Revisited.

BACKGROUND: In 1990, we modified Scopinaro's billopancreatic diversion (BPD); instead of a distal gastrectomy and gastroileal anastomosis, a parietal gastrectomy was performed with nutrients diverted through a duodenal switch. Also, the length of the common channel (50 cm) was doubled to 100 cm, while the nutrient limb remained 250 cm. In 1991, we reported initial results after 16 months, weight loss was as expected following BPD, but patients reported fewer side-effects and the prevalence of excessive malabsorption was less. This cohort of patients had their duodenum stapled shut to construct the duodenal switch. This staple-line failed insidiously in some patients, allowing the duodenum to recanalize partially or completely. This resulted in an incomplete BPD. METHODS: Since 1992, the duodenal switch has been constructed with a complete transaction of the duodenum to prevent recanalization. We report here on the first 61 patients who underwent this definitive procedure. RESULTS: At 16 months, we observed a mean weight loss of 84% of initial excess weight, the number of daily stools at 2.9 +/- 1.6 and the prevalence of diarrhea at 10%. Twenty per cent of patients experienced mild anemia, hypocalcemia, or hypoalbuminemia, which required added supplements. CONCLUSIONS: BPD with parietal gastrectomy, duodenal switch and longer common channel improved weight loss and decreased gastrointestinal side-effects without an increased prevalence of excessive malabsorption. The parietal gastrectomy may contribute to weight loss by increasing satiety, and decreasing side-effects by regulating gastric emptying.

Journal Article↗
PubMed1990

[CT evaluation of bone mineral density (BMD) of lumbar spine in patients after gastrectomy].

The late postoperative complications in patients after gastrectomy include anemia and metabolic bone disorders. We studied to determine whether gastric surgery is associated with metabolic bone disease. Vertebral BMD was measured in 55 patients after gastric resection by using DEQCT (dual energy quantitative CT). Forty patients were symptomatic, having bone or joint pain, history of bone fracture, or dental caries. The control group consisted of 161 patients without metabolic bone disorders. Forty percent of the patients with either the symptoms or history of bone fracture or dental caries, and 20% of the patients without the symptoms or the history showed decreased BMD. BMD was significantly lower in males in their 60s and in females in their 50s and 70s than BMD in age-matched control groups. When male subjects were grouped according to the years following the operation (1-5, 6-10, 11-15, 16-20 years), BMD was found to be decreased in 27%, 29%, 40% and 50% of the patients after surgery. Higher incidence of decreased BMD was found in the patients after total gastrectomy when compared with those after subtotal gastrectomy. Among the patients with subtotal gastrectomy, the incidence of decreased BMD was higher in patients with Billroth II anastomosis than in those with Billroth I anastomosis. In cases with compression fracture on thoracolumbar radiographs, BMD was significantly lower in comparison with cases with no fracture. It was difficult to differentiate between osteomalacia and osteoporosis only by the thoracolumbar radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1960

A study of the pancreatic response to food after gastrectomy in man.

The results of intubation tests on 50 patients before and after gastrectomy have been reviewed. Following gastrectomy, the pancreatic response to food is modified in the following manner.(1) There is an increase in the resting volume of secretion.(2) After a Billroth I operation, the output in one hour after a meal is some two-thirds of the pre-operative output.(3) After a Polya gastrectomy, the pancreas continues to secrete at its resting rate after meals.(4) Dissociation of enzymes occurs in the afferent loop after a Polya operation. Lipase is frequently absent from the intestinal contents, and trypsin occasionally so.(5) Vagal section appears to be an important factor in the production of the new pattern of response.

Folliculitis↗
PubMed1979

Does gastrectomy predispose to amyotrophic lateral sclerosis?

Some authors have suggested that amyotrophic lateral sclerosis (ALS) may be precipitated by a "deficiency factor" following gastrectomy. Methods to establish a statistical association of the disease with gastrectomy include a case-control study. Two such studies have been made in Japan, one involving 712 and the other 158 cases of the diseases. No statistically significant association between gastrectomy and the subsequent occurrence of ALS was found, indicating it is unlikely that the operation predisposes to ALS. None of many other factors studied except mechanical injury showed a statistically significant association in either study.

Amyotrophic Lateral Sclerosis↗
PubMed2000

Pancreas-preserving total gastrectomy for gastric cancer.

BACKGROUND: Pancreas-preserving total gastrectomy for gastric cancer has been proposed to remove lymph nodes along the upper border of the pancreas without performing a distal pancreatic resection. However, the original technique includes the ligation of the splenic artery at its origin and thus carries the risk of pancreatic necrosis. HYPOTHESIS: A technique of pancreas-preserving total gastrectomy that includes ligation of the splenic artery approximately 5 cm distally from the root may reduce the risk of postoperative pancreatic necrosis. DESIGN: Case series. SETTING: Both primary and referral hospital care. PATIENTS: Hospital records of 228 consecutive patients who, according to a personal technique, underwent D3 pancreas-preserving total gastrectomy for gastric cancer from 1981 to 1997 were reviewed. MAIN OUTCOME MEASURES: Surgical complications, postoperative deaths, and survival. RESULTS: Hospital morbidity and mortality were 33.3% and 3.9%, respectively. No patients experienced pancreatic necrosis. The 5-year survival rate after curative resection was 53.6%: 96.9% for stage IA, 76.3% for stage IB, 63.0% for stage II, 35.6% for stage IIIA, 27.0% for stage IIIB, and 20.3% for stage IV (N3-positive patients) disease. CONCLUSION: Results of the present study show the efficacy of this method of radical resection for gastric cancer as demonstrated by the low incidence of postoperative complications and high survival rates.

Adult↗
PubMed1987

Pouch and Roux-en-Y reconstruction after gastrectomy.

We evaluated a reconstruction procedure of the upper gastrointestinal tract after total gastrectomy with the exclusive use of the EEA, GIA, and TA surgical stapling devices (United States Surgical Corp, Norwalk, Conn). Twenty patients with gastric carcinoma entered the study. A total gastrectomy and lymphadenectomy was performed in each patient and the upper gastrointestinal tract was reconstructed by the Roux-en-Y technique with the creation of a Hunt-Lawrence-Rodino pouch. For all operational steps, surgical staplers were used exclusively, as follows: (1) duodenal closure, GIA or TA; (2) Roux-en-Y anastomosis, EEA 25; (3) pouch construction, GIA (three to four times); (4) esophagojejunostomy, EEA 25; and (5) pouch closure, TA 55 or 90. There was a one-hour difference in operating time between patients operated on exclusively by the staple technique and TNM-matched patients operated on manually. Four patients suffered from general complications. Two patients had clinically relevant suture deficiencies. We concluded that current reconstruction methods after gastrectomy that fulfill the reservoir function (pouch) and reflux prevention (Roux-en-Y reconstruction) can be achieved by the combination and systematic use of straight and circular staplers. The advantages are intraoperative time saving and a relaxation of limitations imposed on an abdominal intervention by age and localization of the tumor.

Adult↗