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PubMed1996

Recurrent acute pancreatitis caused by afferent loop stricture after gastrectomy.

Afferent loop obstruction after gastrectomy and Billroth II gastrojejunostomy is only rarely diagnosed as the cause of recurrent acute pancreatitis. Three patients are described in whom afferent loop stricture after gastrectomy and Billroth II reconstruction manifested as recurrent pancreatitis 13 to 24 years after the initial procedure. Late onset, nonspecific symptoms, and other simultaneous gastrointestinal pathologic features promoted a chronic clinical course in all patients. Symptoms included acute abdominal pain, vomiting, jaundice, hyperamylasemia, weight loss, and anemia. A thorough history, barium examination, cholescintigraphy, and endoscopy were central in establishing the diagnosis. The pathogenesis of stricture formation is thought to be ischemic mucosal damage from intestinal crossclamping. Surgical decompression provided lasting relief of the symptoms. Afferent loop stricture should be considered in the different diagnosis in patients with recurrent acute pancreatitis and previous gastrectomy with Billroth II reconstruction.

Acute Disease↗

PubMed1996

N-nitroso compounds in the gastric juice of normal controls, patients with partial gastrectomies, and gastric cancer patients.

BACKGROUND: It has been suggested that the variation of biochemical and microbiological parameters in the gastric juice may play a role in the development of gastric cancer. In the present study we concurrently assessed the presence of N-Nitroso compounds (NOC) and their precursors, bacteria and carcinoembryonic antigen (CEA) in the gastric juice of normal controls, patients with gastric resection, and advanced gastric cancer. METHODS: Detailed analyses of biochemical and microbiological parameters such as pH, nitrite (NO2) concentration, N-nitroso compounds (NOC) concentration, carcino-embryonic antigen (CEA) level, total viable counts (TVC), nitrate-reductase positive bacterial counts (NRPBC), and identification of micro-organisms were carried out. RESULTS: Significantly higher mean pH values, NO2, NOC and CEA concentrations, TVC, and NRPBC were found in partial gastrectomies compared with normal controls, and all these intragastric parameters were significantly higher in patients with gastric cancer than in those with partial gastrectomies. As far as surgical methods are concerned, higher mean pH values, NO2 and NOC concentrations, TVC, NRPBC, and anaerobic bacterial counts were observed in the juice of patients with Billroth II compared with Billroth I gastrectomies. Apart from the type of surgical reconstruction, higher mean NOC levels were recorded in patients with more severe histological changes and H. pylori infection. CONCLUSIONS: All these data suggest that the presence of high levels of NOC in the gastric juice of gastroresected patients can be considered a risk factor of gastric stump cancer.

Adult↗

PubMed1992

Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy.

BACKGROUND: Despite recent advances in diagnosis and treatment, gastric carcinoma remains a major cause of death in the world. METHODS: The clinicopathologic profile of 10,000 consecutive patients who underwent primary gastrectomy during 1962-1989 were reviewed and prognostic factors influencing survival in those with gastric carcinoma were analyzed in 7031 patients. RESULTS: Incidence of gastrectomy for carcinoma has increased steadily and the rate of early carcinoma exceeded that of advanced carcinoma in the recent period of 1985-1989. Five-year and 10-year survival rates were 46.1% and 35.2% in 3868 patients with advanced carcinoma, and 88.8% and 77.3% in 3163 patients with early carcinoma, respectively. In patients with advanced carcinoma, significantly poorer survival rates were noticed for patients older than 70 years of age, those who underwent total gastrectomy, tumors involving the entire stomach or greater than 10 cm in diameter, a macroscopic diffusely infiltrative pattern, adenosquamous histologic type, positive surgical resection margins, or lymph node metastasis. None of the above poor prognostic features were identified in patients with early gastric carcinoma group except for those older than 70 years of age. Although lymph node metastases were present in 10% of early gastric carcinomas, this feature did not impart a poor prognosis. Patients with advanced carcinoma grossly resembling an early carcinoma had an intermediate prognosis, suggesting the existence of a developmentally midstage lesion between early and advanced carcinoma. CONCLUSIONS: The study illustrates that the most important role for clinicians treating with gastric carcinoma should be early detection and aggressive surgery for resectable tumors, followed by detailed pathologic examination.

Adenocarcinoma↗

PubMed1979

Highly selective vagotomy with excision of the ulcer compared with gastrectomy for gastric ulcer in a randomized trial.

Fifty-six patients with benign gastric ulcer of the body of the stomach have been entered into a randomized trial of highly selective vagotomy with excision of the ulcer (HSVE) (26 cases) against standard Billroth I partial gastrectomy (BI) (30 cases). The operations were carried out by all grades of surgical staff. No patient died within 1 month of operation. Postoperative morbidity was greater after gastrectomy than after HSVE. At an average follow-up of about 4 years, functional results according to a modified Visick classification were similar in both groups, with about 75 per cent good results. Two recurrent ulcers occurred after gastrectomy (7 per cent) and 4 after HSVE (15 per cent). Neither operation has a distinct advantage at this stage.

Clinical Trials as Topic↗

PubMed1981

Total gastrectomy for gastric carcinoma: a retrospective study of different procedures and assessment of a new technique of gastric reconstruction.

A retrospective study of the value of reconstructive surgery after total gastrectomy of gastric carcinoma in 118 patients who underwent different types of reconstructive procedures is presented. Dissatisfaction with established methods of reconstruction led to the development of a new technique. The new method was associated with less regurgitation, less dumping and functioned as a reservoir without undue delay in emptying time. It was associated with an improved quality of life in the postoperative period, with minimal dumping symptoms, maintenance of weight and the ability to return to work. The mortality and morbidity of the new method are acceptable and it thus offers not only an improved reconstructive procedure for total gastrectomy after resection for gastric cancer, but offers potential for reconstructive surgery after total gastrectomy carried out for other reasons.

Adult↗

PubMed1988

Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma.

The contention that the R2 radical gastrectomy for localized and potentially curable gastric carcinoma may be superior to gastrectomy without lymphadenectomy (R1) was assessed by randomized trial. Five years after commencement 403 patients have been evaluated at surgery and only 43 (11 per cent) found eligible (S0-2, P0, H0, N0-1), 22 of whom underwent R1 and 21 R2 gastrectomy. Seven patients had final histological stages in excess of the protocol. The R2 group had a longer operating time (P less than 0.005), a greater blood transfusion requirement (P less than 0.005), a longer hospital stay (0.05 greater than P greater than 0.025) and required reoperation in four cases. There were no postoperative deaths. Four patients have died from the disease in the R1 group and five in the R2 group, there being no difference in the probability of survival at a median follow-up of 3.1 years. The small proportion of patients suitable for radical R2 surgery, the high associated morbidity and the fact that survival advantage has yet to be proven in trial suggest that this procedure should not yet be performed outside of controlled clinical trials.

Adult↗

PubMed1990

Pathogenesis of acute cholecystitis after gastrectomy.

The increased incidence of gallbladder diseases after gastrectomy is discussed with regard to contractile motility of the gallbladder. Ultrasonographic findings and contraction of the gallbladder in response to egg yolk or caerulein were studied before and after gastrectomy at intervals ranging from 2 weeks to 6 months. Enlargement of the gallbladder with accumulation of biliary sludge and hypomotility were frequently observed within a month of operation for gastric cancer, suggesting that biliary stasis is an important contributing factor in postoperative acute cholecystitis. Within 3 months of operation, contraction had recovered to close to preoperative levels and the incidence of biliary sludge formation gradually decreased. Daily administration of an opiate antagonist, naloxone (0.8 mg), significantly improved gallbladder dyskinesia and decreased the incidence of biliary sludge formation within 1 month of gastrectomy.

Acute Disease↗

PubMed1990

Failure of nutritional recovery after total gastrectomy.

Malnutrition is reported to be an inevitable consequence of total gastrectomy, although there are few data to support this contention. Six patients of median age 63 years underwent total gastrectomy for malignancy. At follow-up (median 45 months, range 25-60 months) each patient was clinically tumour-free and underwent dietary assessment, faecal fat and nitrogen measurement and routine haematological testing. Protein and fat stores, measured by neutron activation analysis and the tritiated water dilution technique, were compared with the same measurements made before operation and with predicted values. Mean (s.d.) dietary intake (2224(381) kcal day-1 and 81(15)g protein day-1) met the patients' estimated requirements. Mean(s.d.) serum albumin and faecal nitrogen values were normal but there was notable steatorrhoea (21(17) g day-1). Body composition measurements revealed profound deficiencies of body-weight (P less than 0.02), protein (P less than 0.01) and fat (P less than 0.02) before operation which were not corrected by an apparently curative total gastrectomy (P less than 0.05), although further deterioration was prevented.

Adenocarcinoma↗

PubMed1990

Manometric evaluation of jejunal limb after total gastrectomy and Roux-Orr anastomosis for gastric cancer.

Total gastrectomy with Roux-Orr anastomosis is frequently performed for gastric cancer. Since intestinal motility of the Roux limb has never been evaluated after this operation, pressure activity was investigated in the Roux limb of ten patients (aged 51-77 years) who had undergone total gastrectomy and Roux-Orr reconstruction. Investigations were carried out during a 6-h fast and 3 h after a 605 kcal mixed meal. During fasting only two patients had activity fronts and these were abnormal. All ten patients displayed non-propagating bursts of contractions and three had discrete clustered contractions and high amplitude jejunal contractions. The fed state was characterized by a severely reduced motor activity pattern and other abnormalities. Total gastrectomy with Roux-Orr anastomoses provokes a relatively severe disturbance in intestinal activity.

Aged↗

PubMed1993

Kinetic changes and experimental carcinogenesis after Billroth I and II gastrectomy.

To determine the risk of gastric remnant cancer according to the type of surgical reconstruction, the distal two-thirds of the glandular stomach was resected in male Wistar rats, followed by gastroduodenostomy (Billroth I anastomosis) or gastrojejunostomy (Billroth II anastomosis). No carcinogens were given and the animals were killed 50 weeks after operation. No cancers developed in 22 rats undergoing Billroth I gastrectomy, but five of 24 with Billroth II anastomosis had adenocarcinoma (P < 0.05). All carcinomas were confined to the stoma. Animals with Billroth II anastomosis had a more advanced grade of mucosal atrophy at the stoma, with a higher incidence of cystic dilatation, submucosal adenocystic proliferation and pseudopyloric metaplasia (P < 0.05). Cell kinetics in the stomal mucosa after Billroth II gastrectomy showed an increased cell count in the proliferative zone, longer duration of S phase and increased cell cycle time (P < 0.05). These results suggest that Billroth II gastrectomy carries a greater risk of cancer than the Billroth I procedure.

Anastomosis, Surgical↗

PubMed1996

Impact of splenectomy on circulating immunoglobulin levels and the development of postoperative infection following total gastrectomy for gastric cancer.

Splenectomy increases the postoperative morbidity of total gastrectomy for carcinoma of the stomach. The reasons for this increased risk of postoperative infection are unknown. The aim of this study was to evaluate the impact of splenectomy on circulating immunoglobulin levels and to determine whether splenectomy was an independent risk factor for the development of postoperative infection in 154 patients undergoing total gastrectomy for carcinoma of the stomach. Splenectomy reduced circulating immunoglobulin M levels in the early postoperative period following total gastrectomy. However, it was not identified as an independent risk factor for the development of postoperative infection by multivariate analysis.

Female↗

PubMed2004

Prospective study of routine contrast radiology after total gastrectomy.

BACKGROUND: The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation. METHODS: Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy. RESULTS: Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak. CONCLUSION: There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Adult↗

PubMed2005

Prevalence of vertebral alterations and the effects of calcium and vitamin D supplementation on calcium metabolism and bone mineral density after gastrectomy.

BACKGROUND: Bone disease is common after gastrectomy, resulting in decreased bone mass and an increased risk of fracture. No proven therapy is currently available. METHODS: Serum markers of calcium metabolism in 98 patients after partial or total gastrectomy were compared with those in 30 age- and sex-matched healthy controls. Patients with disorders of calcium metabolism were investigated by conventional radiography and single-energy computed tomography of the spine. Forty patients participated in a 1-year follow-up study to investigate the effects of vitamin D and calcium supplementation on calcium metabolism and bone mineral density. RESULTS: Altered serum markers of calcium and phosphate metabolism were observed in 77 (79 per cent) of 98 patients. Sixty (79 per cent) of these had vertebral alterations. Vertebral fractures were detected in 22 patients, grade I vertebral deformities in 50 patients, grade II deformities in 22 patients and osteopenia (Z-score less than - 1) in 30 patients. Calcium and vitamin D supplementation resulted in an increase in 25-hydroxy-vitamin D (P < 0.001), 1,25-dihydroxy-vitamin D (P = 0.048) and osteocalcin (P = 0.045), whereas levels of parathyroid hormone were decreased (P = 0.007). Bone mineral density did not change over time. CONCLUSION: Disturbances of calcium and bone metabolism are common after gastrectomy. Calcium and vitamin D supplementation normalized levels of markers of calcium metabolism and might have prevented age-related bone mass loss, although it did not increase bone mineral density after 1 year.

Biomarkers↗

PubMed1990

Effects of truncal vagotomy and partial gastrectomy on the pharmacokinetics of propranolol enantiomers in dogs.

The effect of partial gastrectomy on the pharmacokinetic parameters of (+)- and (-)-propranolol were investigated in six dogs. (+/-)-Propranolol (3 mg/kg body weight) was administered orally before and after surgery and the plasma concentrations of (+)- and (-)-propranolol were determined using an indirect enantioseparation technique. There were significant differences (p less than or equal to 0.05, paired t-test) in the area under the concentration-time curves (AUCs) and the maximum plasma concentration (Cmax) between (+)- and (-)-propranolol. The ratio AUC(+):AUC(-) was 1.73 +/- 0.28. These differences between the enantiomers remained unchanged after surgery. Other pharmacokinetic parameters showed no stereoselectivity. After partial gastrectomy, there was a slight, but nonsignificant decrease in time to reach maximum plasma concentration (tmax) and in the absorption half-life for both enantiomers. The maximum plasma concentration increased slightly. The elimination half-life and the mean residence time remained unchanged before and after surgery. Therefore, it is unlikely that there are any clinically relevant changes in the pharmacokinetics of (+)- and (-)-propranolol after partial gastrectomy.

Animals↗

PubMed2001

Early complications following total gastrectomy for gastric cancer.

BACKGROUND: The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer. METHODS: A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn. RESULTS: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal. CONCLUSIONS: Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.

Adult↗

PubMed1982

Selection of gastrectomy for adenocarcinomas arising in the gastric fundus.

A retrospective study involving 174 patients with adenocarcinoma of the gastric fundus treated with proximal subtotal (PS), extended proximal subtotal (EPS), total (T), and extended total (ET) gastrectomy showed that 1)there were no statistically significant differences in operative mortality between the four gastrectomy types; 2)ET was associated with a significantly lower incidence of local recurrence than T (P less than 0.05) and PS (P less than 0.001); 3)ET resulted in a significantly higher survival rate than PS or T (P less than 0.01) when the three procedures were applied in patients who had TNM stage I and II tumors; 4)patients with stage III and IV tumors did poorly regardless of gastrectomy type. The study implies that intraoperative tumor staging might identify stage I and II patients who benefit the most from radical surgery and those with stage III and IV tumors who should receive palliative surgery.

Adenocarcinoma↗

PubMed1992

Surgical treatment for thoracic esophageal carcinoma in patients after gastrectomy.

The clinicopathologic factors in 50 gastrectomized and 831 nongastrectomized patients with thoracic esophageal carcinoma were compared. The differences in various factors were not statistically significant except for the average duration of operation, which suggests that the association of esophageal carcinoma and previous gastrectomy is a chance finding. Thirty-four gastrectomized patients underwent abdominal lymphadenectomy and 16 did not. The postoperative survival curves for the two groups did not differ. In comparing the clinicopathologic factors between the two groups, only the tumor location differed significantly (P < .05). Nine patients (26.5%) with lesions in the mid- or lower thoracic esophagus in the gastrectomized group had positive nodes in the abdomen; the 5-year survival rate was 39.4%. Among them, 8 had gastrectomy for peptic ulcer. Abdominal lymphadenectomy is recommended for those patients with mid- or lower thoracic esophageal carcinoma who have had previous gastrectomy without lymphadenectomy.

Carcinoma, Squamous Cell↗

PubMed1993

Relationship between age and the time of surgery and prognosis after gastrectomy for gastric cancer.

We did a retrospective study to assess the influence of age on the prognosis in 1,537 patients with gastric cancer and who underwent gastrectomy. The patients were classified into 7 groups by age at the time of surgery, and the relative survival rates were calculated after correcting for each patient's sex, age, and the operative calendar year, based on the life table data for the general Japanese population. The overall prognoses in patients under age 30 and over age 80 years were poor (for ages under 30 years, 30-39, 40-49, 50-59, 60-69, 70-79, and over 80 years, the 5-year survival rates were 32.1%, 55.9%, 54.8%, 54.3%, 48.6%, 50.8%, and 31.5%, respectively). The poor prognoses in the youngest patients could be attributed to a high frequency of aggressive stage of the tumor. After curative gastrectomy, although the prognoses were excellent for every category in the first and second postoperative year, patients over age 80 years had a relatively poor prognosis after the third postoperative check-up. The poor prognoses in the oldest patients were attributed to the number of deaths due to other diseases. We conclude that for the very young or old subjects, age is a significant prognostic factor for those treated by gastrectomy for gastric cancer.

Adult↗