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PubMed1998

Helicobacter pylori infection in the remnant stomach after gastrectomy: with special reference to the difference between Billroth I and II anastomoses.

Helicobacter pylori infection is associated with many gastric diseases, such as peptic ulcer and gastric cancer. We examined the remnant stomach for H. pylori infection after gastrectomy for gastric cancer or peptic ulcer between October 1992 and July 1997. H. pylori DNA in the gastric juice of 109 patients [mean age 62.4 years, male/female 78/31, gastrectomy for gastric cancer 83/peptic ulcer 26, Billroth I (BI) anastomosis 72/Billroth II (BII) 37, mean postoperative interval 6.0 years] was amplified by PCR and detected by Southern blot hybridization. The serum of 135 patients was assayed by ELISA for IgG antibody against H. pylori (mean age 61.8 years, male/female 99/36, gastrectomy for gastric cancer 111/peptic ulcer 24, BI anastomosis 93/BII 42, mean postoperative interval 5.4 years). H. pylori was positive in 68/109 (62.4%) by PCR and 113/ 135 (83.7%) by ELISA. H. pylori cytotoxin gene cagA, a H. pylori virulence factor gene, was found in 15/16 (93.8%) cases by PCR. A significant difference in H. pylori positivity by PCR was found according to the type of anastomosis (BI vs. BII) but not according to age group, sex, disease (cancer or ulcer), or postoperative interval by PCR and ELISA. BII anastomosis was followed by a significantly lower rate of H. pylori infection (17/37; 45.9%) than BI anastomosis (51/72; 70.8%; p=0.01) according to the results of PCR. Moreover, some patients with BII anastomosis (3/8; 37.5%) showed positive to negative seroconversion for H. pylori infection after the operation (mean 2.47 years) according to the results of ELISA, but this phenomenon was not observed in patients with BI (0/12) anastomosis. This may reflect the role of bile reflux, which is more common in BII than BI, because bile reflux interferes with colonization by H. pylori.

Adult↗
PubMed2000

Successful treatment of percutaneous transhepatic papillary dilation in patients with obstructive jaundice due to common bile duct stones after Billroth II gastrectomy: report of two emergent cases.

Successful treatment of two patients with obstructive jaundice due to choledocholithiasis after Billroth II gastrectomy was performed by elimination of stones by percutaneous transhepatic balloon dilatation of the sphincter of Oddi. Patient 1 was an 82-year-old man and Patient 2 was a 73-year-old man. Both patients presented with obstructive jaundice. The papilla was not observed in either patient because of previous Billroth II gastrectomy. Because an endoscopic approach was impossible, percutaneous transhepatic cholangiodrainage (PTCD) was performed to alleviate jaundice. Choledocholithiasis was treated as follows: The sphincter of Oddi was dilated by percutaneous transhepatic balloon, and stone particles were removed from the papilla with a stone-eliminating balloon catheter via the same route of PTCD. This method is less invasive than the percutaneous transhepatic cholangioscopic method, and the use of existing appliances such as a balloon for papillary dilation is possible. Hence, this method appears to be an effective and simple method for the treatment of choledocholithiasis after gastrectomy that is difficult to treat endoscopically.

Aged↗
PubMed2002

Control of alkaline reflux esophagitis after total gastrectomy by a percutaneous jejunostomy tube.

Postoperative alkaline reflux esophagitis is a potentially devastating complication after total gastrectomy. The advent of the Roux-en-Y reconstruction has significantly decreased the incidence of this complication. However, when reflux esophagitis occurs, it is often refractory to medical treatment. Even though surgical revision of the Roux-en-Y anastomosis is the management option of choice, affected patients (especially those with advanced metastatic cancers) are often poor surgical candidates. We describe a novel treatment of refractory alkaline reflux esophagitis in a patient after radical total gastrectomy with Roux-en-Y reconstruction for advanced gastric carcinoma. Radiologic placement of a percutaneous jejunostomy tube into the proximal jejunal limb resulted in significant symptomatic relief by external diversion of the pancreaticobiliary drainage, and the procedure was associated with minimal discomfort. Nonsurgical pancreaticobiliary diversion should be considered in those patients with refractory alkaline reflux esophagitis that occurs after total gastrectomy.

Esophagitis, Peptic↗
PubMed1989

Pancreatic polypeptide response to food and cerulein in patients with total gastrectomy.

In order to investigate the intestinal phase of pancreatic polypeptide (PP) release, the hormonal response to food and cerulein was measured in 19 patients with truncal vagotomy and total gastrectomy (10 with simple esophagojejunal anastomosis and 9 with an additional duodenojejunal anastomosis) and in 7 healthy subjects. After gastrectomy, the early peak of the physiologic biphasic PP response to food was lost but the late predominant phase was unchanged so that the overall postprandial release of the hormone was not significantly lowered. Gastrectomized patients with duodenal bypass had postprandial serum levels only slightly lower than those of patients with preserved duodenal transit of food. Serum PP response to cerulein stimulation was significantly lower in vagotomized patients than in healthy subjects. However, in operated patients as well as in controls, cerulein infusion did induce a rapid increase of plasma PP, followed by persistently elevated levels. The PP response to cerulein was abolished by atropine pretreatment. Our findings indicate that the intestinal phase of meal-stimulated PP response is not dependent on the integrity of vagal pancreatic innervation and that the preservation of the duodenal transit of food after total gastrectomy is not crucial for the maintenance of the enteroinsular axis.

Adult↗
PubMed1992

Effect of total gastrectomy on remnant islet cell function after major pancreatectomy in rats.

This study was designed to investigate the effect of total gastrectomy on remnant islet cell function after 85% distal pancreatectomy in rats. Eight-week-old Wistar male rats were divided into the following three groups: group 1, laparotomy; group 2, distal pancreatectomy; and group 3, distal pancreatectomy with total gastrectomy. Four weeks after the operation, i.v. glucose tolerance tests (ivGTT) were performed. The body weight in group 3 rats 4 weeks after the operation was significantly lower than that of the other two groups (p less than 0.05). Glucose tolerance was impaired in both groups 2 and 3; group 3 was more impaired than group 2. Immunoreactive insulin (IRI) concentration in both groups 2 and 3 was much lower than that in group 1 throughout the ivGTT. Furthermore, IRI concentration in group 3 was lower than group 2 at all times. The integrated secretion of insulin for the 45 minutes after glucose injection was lower in group 3 than in group 2. It is concluded that total gastrectomy injures remnant pancreatic endocrine function after 85% distal pancreatectomy in rats.

Animals↗
PubMed2001

Laparoscopy-assisted distal gastrectomy for gastric malignant lymphoma.

Although the best treatment for gastric malignant lymphoma remains a controversial matter, surgery is the first choice for localized malignant lymphoma without lymph node metastasis and invasion to the adjacent organ. We report a case of gastric malignant lymphoma that was managed with laparoscopy-assisted distal gastrectomy. A 47-year-old man was referred to our department for management of gastric lymphoma. After preoperative examination revealed a tumor confined to the gastric wall but no lymph node metastasis, we performed laparoscopy-assisted Billroth I gastrectomy. Histopathologic examination confirmed that the tumor was follicular center lymphoma limited to the submucosa with no lymph node metastasis. The postoperative course was good. This is the first reported case of laparoscopic gastrectomy-treated gastric malignant lymphoma. Because it involves minimal access and invasiveness, this procedure may be an effective method of treatment of localized malignant lymphoma of the stomach.

Gastrectomy↗
PubMed2003

Laparoscopy-assisted D2 subtotal gastrectomy in early gastric cancer.

The purpose of this study is to prove the safety and efficacy of laparoscopy-assisted subtotal gastrectomy and D2 lymph node dissection using 4 ports and an EEA stapler with a Billroth I anastomosis. From 1999 to 2001, 20 patients with EGC located in the distal stomach underwent laparoscopy-assisted Billroth I gastrectomy (LABIG). A 4-port-technique was performed for omentectomy, vascular ligation, and D2 lymph node dissection. A mini-incision was created between the two ports in the epigastric area and a gastroduodenal anastomosis with an EEA stapler and a distal resection was performed. The mean operating time was 261.8 (170-410) minutes. There was one postoperative complication without any intraoperative transfusions or perioperative mortality. The number of harvested nodes was 31.9 +/- 11.4. Mean distance from the lesion to the margin of resection was 5.3 +/- 2.2 cm proximally and 4.0 +/- 2.0 cm distally. On average, oral liquids were started at the 4.7th (3rd-8th) postoperative day. LABIG is a safe and effective way of performing D2 gastrectomy in terms of morbidity and oncological principles. A randomized controlled clinical study to compare long-term survival and quality of life is warranted.

Abdomen↗
PubMed2006

Parenteral N-3 fatty acids modulate inflammatory and immune response in rats undergoing total gastrectomy.

This study investigated the effect of n-3 fatty acid (FA)-containing parenteral nutrition on the circulatory lymphocyte subpopulation, intracellular cytokine and leukocyte adhesion molecule expression, and phagocytic activity in rats undergoing total gastrectomy. Normal rats with internal jugular catheters were assigned to normal control (NC) and two experimental groups and received total parenteral nutrition (TPN). At the same time, a total gastrectomy was performed in the experimental groups, whereas the NC group underwent a sham operation. The TPN solutions were isonitrogenous and identical in nutrient compositions except for differences in fat emulsion contents. The NC and one of the experimental groups received a soybean oil emulsion (SO), and the other experimental group received 50% soybean oil and 50% fish oil emulsion (FO). Half of the rats in each respective group were sacrificed 1 or 3 days after surgery or the sham operation to examine their immune response. The results showed that the FO group had a higher CD4 proportion and CD4/CD8 ratio than those of the SO and NC groups postoperatively. The phagocytic activity of peritoneal macrophages was higher in the FO group than in the NC group, but no difference was found between the SO and NC groups 3 days after surgery. The intracellular interferon (IFN)-gamma distribution in the FO group was higher than that of the SO group on postoperative days. Leukocyte adhesion molecule expressions and peritoneal monocyte chemotactic protein-1 levels were lower in the FO group than in the SO group on postoperative day 3. These results suggest that parenterally infused FO did not result in immunosuppression. In addition, FO administration promotes lymphocyte Th1 cytokine production, enhances peritoneal macrophage phagocytic activity, and reduces leukocyte adhesion molecule expression in rats with total gastrectomy.

Animals↗
PubMed2003

Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients.

OBJECTIVE: This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume. SUMMARY BACKGROUND DATA: The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship. METHODS: A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume. RESULTS: Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10). CONCLUSIONS: For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.

Aged↗
PubMed2005

Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial.

OBJECTIVE: The aim of this study was to compare technical feasibility and both early and 5-year clinical outcomes of laparoscopic-assisted and open radical subtotal gastrectomy for distal gastric cancer. SUMMARY BACKGROUND DATA: The role of laparoscopic surgery in the treatment of gastric cancer has not yet been defined, and many doubts remain about the ability to satisfy all the oncologic criteria met during conventional, open surgery. METHODS: This study was designed as a prospective, randomized clinical trial with a total of 59 patients. Twenty-nine (49.1%) patients were randomized to undergo open subtotal gastrectomy (OG), while 30 (50.9%) patients were randomized to the laparoscopic group (LG). Demographics, ASA status, pTNM stage, histologic type of the tumor, number of resected lymph nodes, postoperative complications, and 5-year overall and disease-free survival rates were studied to assess outcome differences between the groups. RESULTS: The demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 33.4 +/- 17.4 in the OG group and 30.0 +/- 14.9 in the LG (P = not significant). Operative mortality rates were 6.7% (2 patients) in the OG and 3.3% (1 patient) in the LG (P = not significant); morbidity rates were 27.6% and 26.7%, respectively (P = not significant). Five-year overall and disease-free survival rates were 55.7% and 54.8% and 58.9% and 57.3% in the OG and the LG, respectively (P = not significant). CONCLUSIONS: Laparoscopic radical subtotal gastrectomy for distal gastric cancer is a feasible and safe oncologic procedure with short- and long-term results similar to those obtained with an open approach. Additional benefits for the LG were reduced blood loss, shorter time to resumption of oral intake, and earlier discharge from hospital.

Adult↗
PubMed1990

Carcinoma of the stomach: a review with special reference to total gastrectomy.

Five hundred and eleven patients with adenocarcinoma of the stomach were reviewed. Weight loss and abdominal pain were the most common symptoms. One-third of patients were found to have proximal gastric lesions with dysphagia being a major symptom in 23% of all patients. Laparotomy was performed on 88% of patients with 56% of the entire series undergoing gastric resection. The overall 5-year survival rate was 12.3% and for curative resection 43%. The 5-year survival rate of patients undergoing total gastrectomy was 53% and for patients undergoing subtotal or partial gastrectomy the 5-year survival rate was 42%. The operative mortality, similar in both groups, was 8.1% versus 5.6%. Palliation was better achieved by resection than bypass. Total gastrectomy for palliation was undertaken in 48 patients. This group of patients has achieved a good quality of life and a mean survival rate of 12.5 months.

Adenocarcinoma↗
PubMed2003

An impaired accommodation of the proximal stomach to a meal is associated with symptoms after distal gastrectomy.

OBJECTIVE: The aim of this study was to assess gastric emptying and postprandial proximal gastric tone variations depending on the presence of postoperative symptoms after Billroth II gastrectomy (BII). METHODS: A total of 16 consecutive patients were prospectively studied 10 +/- 3 months after distal gastrectomy for antral cancer. No evidence of cancer recurrence was detected at the time of the study. Ten patients were asymptomatic after surgery, whereas six patients were considered as symptomatic because of at least one weekly epigastric pain, postprandial fullness, nausea, or vomiting. The fasting fundus volume and tone, the onset of a gastric relaxation after a standard 200-kcal liquid meal, and the characteristics of this relaxation (delay of occurrence, amplitude) were determined with a barostat. Patient results were compared to normal values obtained in 12 healthy volunteers. Gastric emptying studies were performed in all patients using the C(13) acid octanoic breath test after a 250-kcal meal. RESULTS: In the patients, both fasting fundus tone (BII 7.0 +/- 0.5, controls 8.4 +/- 2.4 mm Hg) and volume (BII 108 +/- 11, controls 119 +/- 29 ml) were not different from controls. Fasting fundus tone was lower in asymptomatic patients than in symptomatic patients (6.5 +/- 0.4 vs 8.1 +/- 0.5 mm Hg, p < 0.04). Gastric relaxation was observed immediately after the meal in all asymptomatic patients as well as in controls. In contrast, gastric relaxation occurred in only two of six symptomatic patients (p < 0.01); when it occurred it was delayed by the meal and was observed only 23 +/- 1 min after food intake. When a relaxation occurred, its amplitude was higher than that observed in controls both in asymptomatic and symptomatic patients (294 +/- 21 vs 179 +/- 53 ml, p < 0.02). CONCLUSIONS: After distal gastrectomy, gastric accommodation is impaired (i.e., absent or delayed) in symptomatic patients. When relaxation exists in these patients, its amplitude is higher than in control subjects.

Adult↗
PubMed2005

Small-bowel metaplasia arising in the remnant esophagus after esophagojejunostomy--a [corrected] prospective study in patients with a history of total gastrectomy.

OBJECTIVES: The pathogenesis of Barrett's mucosa is incompletely understood. Acidic gastro-esophageal reflux is considered an essential causative factor. The aim of this study was to detect esophageal columnar metaplasia after total gastrectomy with esophagojejunostomy, a condition of enteric, but nonacidic reflux. METHODS: In a prospective study, patients with a history of total gastrectomy and esophagojejunostomy were investigated for the presence of columnar metaplasia in the remnant esophagus. Patients with such history, who were now referred for esophagogastroduodenoscopy, were included during a 2-yr period. Biopsies for histopathology were taken from the anastomosis and any columnar metaplasia of the esophagus. RESULTS: In 8 of 25 patients (32%) with a history of gastrectomy, columnar metaplasia was found in the remnant esophagus, mostly in shape of tongues, partly associated with erosive reflux esophagitis. Histopathology showed a typical small-bowel mucosa, but with some villous atrophy. In a resection specimen, a double-layered muscularis mucosa was present, which proved the metaplastic nature of the intestinal mucosa. Length of the columnar metaplasia correlated with the time interval since surgery. CONCLUSIONS: Esophageal mucosa, if exposed long term to an enteric, but nongastric refluxate, can evolve into a highly differentiated intestinal metaplasia, which resembles small-bowel mucosa. This proves that complete-type intestinal metaplasia may arise not only in the stomach, but also in the esophagus. Esophageal intestinalization seems to reflect adaptation to enteric reflux.

Aged↗
PubMed2005

Fructooligosaccharide consumption improves the decreased dentin formation and mandibular defects following gastrectomy in rats.

OBJECTIVE: We examined the effects of fructooligosaccharides (FOS) consumption on gastrectomy-evoked osteopenia and disorders of dentin formation in rats. MATERIALS AND METHODS: Male Sprague-Dawley rats (n = 28, 35-day old) were equally divided into two groups; sham-operated and gastrectomized, and sham-operation or total gastrectomy was performed. Four weeks after each surgery, the rats were divided into two sub-groups (n = 7 each); with or without 7.5% FOS-feeding for 6 weeks. Backscattered electron images of the mandibular sections were taken to calculate trabecular bone area, cortical bone area and total scan area. Thereafter, the dentin formation rate in maxilla were calculated using a fluorescent microscope. RESULTS: Trabecular bone area and cortical bone area in GX rats were markedly decreased. FOS-feeding significantly counteracted this reduction, but not to the level seen in sham-operated rats. Total scan area in gastrectomized groups was significantly decreased. The dentin formation rate was not statistically different among the groups, except the gastrectomized group. CONCLUSION: These results suggest that FOS consumption partially restored osteopenia and almost completely restored the reduction in dentin formation following gastrectomy in rats.

Animals↗
PubMed1971

The effect of fat on calcium absorption from a mixed meal in normal subjects, patients with malabsorptive disease, and patients with a partial gastrectomy.

The absorption of (47)Ca Cl(2) taken with a milk and porridge meal was measured in normal subjects, patients with a partial gastrectomy, and patients with malabsorption. The addition of palm oil to the meal depressed calcium absorption, whereas the addition of medium-chain triglyceride had no effect. The contrasting effect of the two fats on calcium absorption was most marked in patients with a partial gastrectomy and least marked in patients with malabsorption. In patients with malabsorption, impairment of calcium absorption was most marked in the patients with a significant increase in faecal fat excretion. Absorption of calcium was greater in patients with a partial gastrectomy than in normal subjects.

Calcium↗
PubMed1999

Proximal gastrectomy and gastric tube reconstruction for early cancer of the gastric cardia.

BACKGROUND: Advances in diagnostics and techniques have increased the number of detections of early cancer of the gastric cardia. The aim of this report is to describe a new technique of proximal gastrectomy and gastric tube reconstruction using an autosuture stapler. METHODS: At operation, the upper part of the stomach was fully mobilized, and the abdominal esophagus was transected. The stomach was cut between the points of the distal three fourths of the lesser curvature and a half of the greater curvature, and a gastric tube measuring 20 cm in length and 4 cm in width was made. A circular stapler was inserted through a stapled line, and direct anastomosis between the esophagus and gastric tube was completed. RESULTS: When compared with the patients who underwent proximal gastrectomy and jejunal interposition, those who underwent gastric tube reconstruction showed a significantly shorter operation time. All 3 patients who underwent proximal gastrectomy and gastric tube reconstruction recovered uneventfully and took foods satisfactorily. Good passage through the gastric tube was recognized on roentgenography, and reflux esophagitis or stomal ulcer was not found on fiberscopy. CONCLUSIONS: We believe the procedure is technically simple and safe, and provides good postoperative results in patients with early cancer of the gastric cardia.

Adenocarcinoma, Mucinous↗
PubMed2003

Lymphatic mapping and sentinel node biopsy during laparoscopic gastrectomy for early cancer.

BACKGROUND/AIMS: Intraoperative lymphatic mapping and sentinel node (SN) biopsy can potentially be combined with minimally invasive surgery, but there are few reports of laparoscopic lymphatic mapping for gastrointestinal cancer. We examined the feasibility and accuracy of laparoscopic lymphatic mapping in predicting lymph node status in patients with gastric cancer. METHODS: Seventeen patients with gastric cancer invading the mucosal or submucosal layers (T1) underwent laparoscopic gastrectomy with lymphatic mapping between March 2001 and May 2002. The day before surgery, a technetium-99m-labelled tin colloid solution was injected endoscopically around the tumor. Immediately after the pneumoperitoneum, patent blue was injected. Gastrectomy was performed in all patients, and blue-stained or radioactive nodes were defined as SNs. Fresh SNs were immediately processed for frozen-section examination by hematoxylin-eosin (H and E) and immunohistochemical (IHC) staining. All non-SNs harvested from resected specimens were subjected to histological examination with H and E. RESULTS: SNs were detected in all patients by combination of the two kinds of tracers. Three patients had lymph node metastases in their final examination, and SNs in these 3 were operatively diagnosed as positive by H and E or IHC staining. Lymphatic mapping and SN biopsy under laparoscopic surgery were performed with 100% accuracy. CONCLUSION: Our preliminary study shows the feasibility of intraoperative lymphatic mapping in laparoscopic gastrectomy for T1 gastric cancer.

Adult↗
PubMed2006

Antireflux contrivance in jejunal pouch reconstruction after total and proximal gastrectomies.

BACKGROUND/AIM: In the reconstruction after gastrectomy, a jejunal pouch may be inferior as a gastric substitute to an isoperistaltic jejunum in terms of preventing reflux. We have developed an antireflux contrivance. METHODS: A jejunal pouch was made by side-to-side anastomosis of both limbs of the jejunum folded into an inverted U, leaving a bridge of the jejunum 15 cm long at the top of the jejunal pouch (apical bridge). The apical bridge is cut near its oral end, and esophagojejunostomy is done, leaving the isoperistaltic jejunum 6-8 cm long positioned between esophagus and jejunal pouch. RESULTS: This antireflux contrivance was performed in 37 patients undergoing total gastrectomy and in 22 patients undergoing proximal gastrectomy. There were no operative deaths in this series. Neither anastomotic bleeding nor anastomotic leakage were observed. In a questionnaire survey, 5 patients answered that they had had heartburn twice a week or more often, but the answer was not repeated by any patient. On endoscopic examination, all patients but 1 had normal findings for the esophagus. Mild esophagitis was observed in 1 patient. CONCLUSION: The antireflux contrivance reported here can be easily, safely, and uniformly done, and it is a useful technique.

Anastomosis, Surgical↗