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PubMed1990

[Comparative analysis in gastric cancer of total gastrectomy extended with lymphadenectomy and the other surgical technics. 10 years' experience].

Of 220 patients operated for gastric cancer, 74 with subtotal gastrectomy and 145 with total gastrectomy (60 with lymphadenectomy), the results and indications for total gastrectomy extended with lymphadenectomy are analysed. The importance of lymph node emptying in relation to the possibility of breakdown of the lymphnode chains with R2 metastasis is particularly stressed. Analysis of perioperative mortality and long-term survival indicates results that are close to the data reported by Japanese schools.

Adult↗
PubMed1990

[Malnutrition after total gastrectomy].

We studied food intake and nutritional status of 28 patients who had undergone total gastrectomy for gastric cancer. At discharge, patients were instructed to keep a high protein, high calorie diet and to record food intake on a specific form, twice weekly. Nutritional follow-up, consisting in a computerized determination of dietary intake and nutritional assessment was performed monthly during the first postoperative year. The average calorie intake was 1,431.8 Kcal/day one month after operation and 2,225.4 Kcal/day one year after surgery (p less than 0.001). In particular, only one patient exceeded 2,000 Kcal/day one month after total gastrectomy, while 21 patients exceed 2,00 Kcal/day one year after operation. The evaluation of nutritional parameters in the postoperative course showed that a significant increase in body weight, serum albumin and total iron binding capacity was observed only in patients who exceed 2,000 Kcal/day one year after operation. These results indicate that malnutrition is not an inevitable consequence of total gastrectomy; in fact, a close relationship between calorie intake and the variations of nutritional parameters was observed.

Adult↗
PubMed1989

[Comparative scintigraphic functional study of 3 different reconstruction technics following total gastrectomy].

Esophago-jejunal reconstruction, after total gastrectomy, is best performed by one of the following three operations: interposed jejunal loop, Roux-en-Y loop and "omega" loop with Braun anastomosis. To assess the effects of the three mentioned techniques three groups of 15 patients each were examined after total gastrectomy for I, II or III stage cancer. Four to ten months after surgery all patients underwent the following tests: a) esophago-jejunal transit with labeled solid meal; b) cholangio-scintigraphy and c) absorption test of biliary acids. A group of 10 patients, without gastrointestinal pathology, was selected for comparison. The data obtained from the comparative study, in agreement with the opinions held by many Authors and our previous research, demonstrate that the interposition of jejunal loop (Mouchet) is the reconstructive technique closest to the unoperated stomach and, for this reason, is to be preferred after total gastrectomy.

Bile Acids and Salts↗
PubMed1989

Ectopic jejunal pacemakers and enterogastric reflux after Roux gastrectomy: effect of intestinal pacing.

The aims of this study were to determine whether ectopic pacemakers are present in the Roux limb of dogs after vagotomy and Roux gastrectomy, whether these pacemakers lead to enterogastric reflux, and whether abolishing the pacemakers with electric pacing might correct such reflex, were it to occur. In five dogs that had undergone gastric vagotomy and Roux gastrectomy and five dogs that had undergone gastric vagotomy and Billroth I gastrectomy (controls), myoelectric activity of the Roux limb or duodenum was recorded during saline infusion (154 mmol/L NaCl) or nutrient (Meritene) infusion into the limb or the duodenum. Reflux of infusate into the stomach was determined via a gastric cannula. Tests in Roux dogs were done with and without limb pacing. Roux dogs showed ectopic pacemakers in the Roux limb that drove the pacesetter potentials of the limb in a reverse, or orad, direction during 76% of the recordings; Billroth dogs rarely had such pacemakers (p less than 0.001). Enterogastric reflux occurred in both groups of dogs but was greater during phase III of the interdigestive migrating myoelectric complex in Roux dogs (12% +/- 6%) than in Billroth dogs (3% +/- 1%; p less than 0.05). Pacing abolished the ectopic pacemakers in the Roux dogs and reduced enterogastric reflux from 12% +/- 6% to 3% +/- 2% when phase III was present (p less than 0.05). In conclusion, the Roux limb was driven by ectopic pacemakers that contributed to, but were not solely responsible for, jejunogastric reflux. Pacing abolished the ectopic pacemakers and decreased reflux when phase III was present in the limb.

Action Potentials↗
PubMed1989

[Prognostic significance of the Lauren classification of patients with stomach carcinoma. A statistical analysis of long-term results following gastrectomy].

To evaluate the prognostic difference between the 2 major histological types of Lauren classification in gastric cancer, data on patients who underwent the same surgical procedure -- total gastrectomy -- were studied. 124 consecutive total gastrectomy cases treated from 1979 to 1986 were classified according to Lauren retrospectively into 2 groups, comprising 63 patients (50.8%) with intestinal type carcinoma and 61 in another group of diffuse (n = 44, 35.5%) or mixed type (n = 17, 13.7%) carcinoma. In regard to extent of total gastrectomy the two groups were comparable (splenectomy 50 times and compartment II lymphadenectomy 43 times in the intestinal type group, vs 49 and 39 times in the diffuse or mixed type group). The proportion of males (42 men, 21 women) and older patients (mean: 62 years) was greater in the intestinal type group than in the group of diffuse or mixed type carcinoma (34 men, 27 women, mean: 57 years). According to TNM stage no significant difference was observed in local tumor infiltration (pT stage), lymph node metastases (pN) and distal metastases (pM) between the two groups at the time of surgery. The stages of disease (UICC 1987) were similar in the two groups: Stage I: intestinal type 25.4% (16/63), diffuse or mixed type 23% (14/61), stage II: 19% (12/63) vs 14.7% (9/61), stage III: 14.3% (9/63) vs 19.7% (12/61), stage IV: 41.3% (26/63) vs 42.6% (26/61). The hospital mortality was 9.5% (6/63) in the intestinal-type group and 8.5% (5/61) in the group of diffuse or mixed carcinoma (no significant difference).(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed1989

[Immediate prognosis factors in total gastrectomy in cancer].

We present a series of 76 patients operated over a period of nine years, diagnosed as gastric cancer (CG), in whom radical oncologic total gastrectomy (GT) with esophago-jejunal anastomosis (EY) on a Roux-en-Y loop (Y-R) was performed. The tumor was located in the cardias in 27 patients, body in 37, fornix in 3, gastric stump in 7 and over plastic linitis in 2. We performed total gastrectomy enlarged to the spleen in 63 patients, to the pancreas in 28, to the colon in 5 and to the liver in 4. We describe the most salient technical details of the surgical intervention. Twenty-six percent of the patients presented postoperative complications, which we divided into two groups: anastomosis failures, among which are emphasized 4 severe esophagojejunal fistulas, a fistula of the duodenal stump (MD) and respiratory complications. The mortality was 7.8%, corresponding to 4 esophago-jejunal fistulas, 1 fistula of the duodenal stump and 1 bilateral bronchopneumonia. We analyzed various parameters that we consider important prognostic indicators of postoperative morbi-mortality. Applying the Fischer test, we attempted to assign statistical significance to these parameters. Age over 60 years increased postoperative mortality. Super-radical surgery did not increase mortality. On the other hand, patients in stages IIIb and IV have a worse prognosis, with a mortality in the first 30 days of 28.5%. Esophago-jejunal anastomosis on a Roux-en-Y loop is the procedure of choice used by our center after total gastrectomy for gastric cancer, yielding the most acceptable morbi-mortality figures.

Adult↗
PubMed1989

Prospective comparison of gastric secretory function after gastrectomy with either Billroth II or Roux-en-Y anastomosis.

In order to delineate the role of enterogastric reflux in changes of postoperative gastric secretory functions, 22 patients with peptic ulcers, who were randomly assigned to partial gastrectomy without vagotomy with either Billroth II or Roux-en-Y anastomosis, were prospectively studied before and 6 months after surgery. Preoperatively, there were no significant differences in gastric secretory functions between the two groups of 11 patients. Postoperatively, median fasting bile acids in the stomach increased in the Billroth II patients from 0.35 to 16.10 mumol/hr (p less than 0.01), but significantly decreased in the Roux-en-Y patients from 0.30 to 0.10 mumol/hr (p less than 0.05), which indicated adequate prevention of enterogastric reflux after the Roux-en-Y procedure. Gastrectomy resulted in significant reductions of median values of basal acid output (4.6 vs 0.6 mmol/hr, p less than 0.01, and 4.2 vs 0.4 mmol/hr, p = 0.02), peak acid output (31.6 vs 4.2 mmol/hr, p less than 0.01, and 38.7 vs 4.5 mmol/hr, p less than 0.01), serum pepsinogen A (121 vs 86 micrograms/L, p less than 0.01, and 92 vs 45 micrograms/L, p less than 0.01), meal-stimulated serum gastrin secretion (1472 vs 199 pM.60 min, p less than 0.0001, and 1017 vs 199 pM.60 min, p less than 0.0001) in the patients with Billroth II and Roux-en-Y anastomosis, respectively. There were, however, no significant differences in gastric secretory parameters between the two groups when studied 6 months after surgery. Therefore it is concluded that after gastrectomy, enterogastric reflux does not affect the secretory function of the gastric remnant within the first 6 months after surgery.

Anastomosis, Roux-en-Y↗
PubMed1988

The surgical treatment of gastric cancer: a retrospective study with special reference to total gastrectomy.

A retrospective study of 312 consecutive cases of gastric malignancy treated from 1974 to 1984 is presented. Eighteen patients (6%) had gastrointestinal lymphoma of the stomach. Among the remaining 294 cases with gastric carcinoma, 46 (16%) had carcinoma of the gastric stump after previous resection for peptic ulcer. Fifty-seven percent (167/294) had no distant metastases (MO). Early gastric carcinoma (pT1) occurred in 16 patients (5.8%), among whom four had distant metastases (pT1M1) and another two patients had regional lymph node metastases (pT1N1). Thirty-three percent of the patients had either no surgical treatment or an explorative laparotomy only, and 9% had a palliative bypass operation performed. A curative (48%) or palliative (10%) resection of the stomach was possible in 171/294 patients. Thus, the resectability rate was 58%. Total gastrectomy was performed in 108 cases with either curative (100) or palliative (eight) intention. The 30-day mortality was two and one patients, respectively (2.8%). Crude survival in the whole series was 16% and 11% at 5 and 10 years. After non-randomized curative total gastrectomy (100 cases) or gastric resection (40 cases) crude survival was 40% and 22% at 5 years, and 24% and 16% at 10 years, respectively (P greater than 0.05, n.s.). We found that total gastrectomy with extensive dissection and end-to-end esophago-jejunostomy by the EEA stapler can be performed with a low mortality rate (2% after curative operation) even in the upper age groups.

Adenocarcinoma↗
PubMed1988

[Effects of duodenogastric bile reflux on gastric mucosal hexosamine concentrations after selective proximal vagotomy or extended distal gastrectomy for duodenal ulcer].

Effects of duodenogastric reflux (DGR) of bile on hexosamine concentrations in gastric mucosa were studied in 17 healthy controls and 133 patients with duodenal ulcer patients before and after surgery. Total bile acid concentration in gastric juice was measured using enzyme method to estimate DGR. Mucosal hexosamine concentration of the biopsy specimens taken from the gastric corpus and antrum was measured according to Boas's method. The operative procedures included selective proximal vagotomy (SPV) with or without pyloroplasty, and extended distal gastrectomy with Billroth I(BI) or II(BII) anastomosis. The rate of DGR were significantly higher in cases after gastrectomy, especially in BII cases than in cases after SPV. In the early postoperative period after SPV with or without pyloroplasty, DGR was increased significantly. However, the reflux rate was decreased gradually to the preoperative level thereafter, suggesting that normal function of gastric emptying might be recovered with time. The hexosamine concentration of the antral mucosa showed clearly an inverse relationship to the changes in DGR rate. These results suggested that SPV could be the more physiological procedure than gastrectomy from the point of DGR.

Bile Acids and Salts↗
PubMedDate not supplied

[Value of automatic sutures in total gastrectomy for cancer: apropos of 81 patients].

We reviewed the results of stapled circular (EEA) and linear (TA 30 or 55) anastomoses in a prospective study of 40 total gastrectomies for cancer, using an interposed jejunal limb (Henley technique). There were 63 circular anastomoses: 40 esophago-jejunal, 20 jejuno-duodenal and 3 jejuno-jejunal anastomoses. Forty patients were submitted to 41 linear stapled closures of the jejunal stump. Technical failure rate with stapled anastomoses was 5% (3 out of 63). Incidence of anastomotic leak was 6.3% for all the circular stapled anastomoses tried and 5% if the 3 technical failures were excluded. Anastomotic leakage is more often associated to splenopancreatectomy. One patient (1% of all the anastomoses) presented gastro-intestinal bleeding, related to the suture line. A conservative treatment was carried out successfully. The mean follow-up time of the surviving patients was 27 +/- 20 months: there was a 5.5% rate of late anastomotic stenosis; all the patients were cured by esophageal dilations. Late anastomotic stenosis is directly related to associated cobalt therapy. Analysis of an older retrospective series of 41 hand-sutured total gastrectomies allowed a comparison to be made between stapled and sutured anastomoses in total gastrectomy for cancer.

Adult↗
PubMed1987

[Dynamic scintigraphy of the liver using 131I-rose bengal and the bile acid content of the blood following gastrectomy for cancer].

Liver function was studied in 84 patients with operable stomach cancer prior to and at varying times after gastrectomy using dynamic scintigraphy with 131I-rose bengal and determination by a radioimmunoassay of bile acids in the peripheral blood. A group of patients without signs of focal lesion of the liver and a history of its diseases was examined. It was shown that disorders of hepatocytic function took place before the operation. After gastrectomy the disorders were accompanied by considerable retardation of the basal secretion of bile into the intestine. At the same time an increase in the concentration of bile acids in the peripheral blood above the discriminant level of healthy persons, i.e. over 0.5 mg/l was observed. Disorders of liver function were of long duration and persistent over 1 year after gastrectomy.

Bile Acids and Salts↗
PubMed1987

[Clinical significance of a physical activity index based on calorimetry in the assessment of quality of life after total gastrectomy].

In order to characterize the objective diagnostic criteria concerning quality of life (QL) of patients after total gastrectomy, a physical activity index (PAI) or a concept of daily physical activity was developed. Sixty patients of gastric cancer, of whom 38 patients underwent long loop Roux-en-Y gastrojejunostomy (LLRY) procedure after total gastrectomy, 13 patients gastroduodenostomy (Billroth I) and 9 patients gastrojejunostomy (Billroth II) after subtotal gastrectomy, respectively, were evaluated as part of this study. In addition, 3 cases of pancreatoduodenectomy (PD) and 5 cases of total esophagectomy were also evaluated. The evaluation of QL was based upon a clinical assessment and administration of patient questionnaire. The assessment of the PAI was performed by measuring the individual's whole day energy expenditure based upon 24 hour heart rate ratio (24h-HRR) method and the basal metabolic energy expenditure. The daily physical activity was graded into four categories according to the PAI value; light, moderate, moderately heavy and heavy. The results obtained were as follows: The value of the energy expenditure predicted by 24h-HRR method and that based on the results of bicycle ergometry (VO2/HR method) showed close correlation. There was no significant difference in the whole day energy expenditure among four operative procedure groups (Billroth I, Billroth II, LLRY and total esophagectomy). More than 80 per cent of LLRY patients, whose QL was evaluated as "excellent" or "good", showed no less than "moderate" PAI. In addition, one of the four patients whose QL was "fair" was categorized into "light" and the remaining three were "moderate".(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1987

Postprandial hyperglycemia after different carbohydrates in patients with total gastrectomy.

Eating related difficulties and symptoms and postprandial serum glucose levels were studied in 11 patients (44 to 70 years old) five to 48 months after total gastrectomy and Roux-en-Y reconstruction for carcinoma of the stomach with no signs of metastasis or residual tumor. Three tests were used. The first contained 150 milliliters of 50 per cent glucose alone, the second had 150 milliliters of 50 per cent glucose with 5 grams of guar gum (viscose dietary fiber) and the third was a vegetable meal containing 75 grams of glucose. All of the patients with total gastrectomy had eating related symptoms, such as dumping and difficulties with the large volume of a meal. They had to eat small meals and the most usually experienced postprandial symptoms were abdominal pain, nausea and faintness. The postprandial serum glucose level was highest after drinking glucose alone and the lowest after eating the vegetable meal (as the highest 9.4 +/- 2.0 and 6.2 +/- 1.6 millimole per liter, respectively, 50 minutes postprandially, p less than 0.01). Hyperglycemia was associated with nausea, sweating, faintness, reduction of blood pressure and increase of pulse rate. The large volume of the vegetable meal produced difficulties (dysphagia and abdominal distension) in eating for everyone except one patient. Guar gum eaten with glucose reduced the postprandial hyperglycemia near to the level found after the vegetable meal. Also, the symptoms experienced after glucose with guar gum reduced from that after glucose alone, five patients became symptomless. Four of these five patients have supplemented guar gum regularly for several months into their daily meals with the result of reduction of the postprandial subjective symptoms. The dose has been adjusted individually from 2 to 7 grams of guar gum three times daily. Loose stools and diarrhea may occur at the beginning. These are avoided by a gradual increase of the dose during an adaptation period of two weeks. Sometimes glucose with guar gum may result in hypoglycemia with prolonged symptoms after immediate hyperglycemia. It is concluded that guar gum gives a possibility to avoid the symptoms related to a large volume of a meal and to reduce those produced by a high glucose content of a meal in patients after total gastrectomy. Guar gum also works in practical prolonged use when the dose is estimated from postprandial symptoms.

Adult↗
PubMedDate not supplied

Roux-en-Y gastrectomy: early and late results.

Results obtained in 16 patients by Roux-en-Y gastrectomy (Moskowicz procedure) are presented. According to Langhans a high gastrectomy ascending on the lesser curvature to 2 to 3 cm below the cardia and unaccompanied by a sectioning of the vagal branches was performed. The Roux-en-Y resection was used only in exceptional situations, being preferred to the standard Billroth II operation in order to avoid the biliopancreatic reflux into the gastric remnant. It was performed as a primary intervention in 13 cases (penetrating gastric or duodenal ulcers, gastritis due to biliar reflux) and as a revisional surgery in three patients with disturbances of the operated stomach. The best results were obtained in gastritis due to biliar reflux, in gastric ulcers Johnson I type, and when the method was used as a revisional surgery. When it was used as a primary operation in duodenal ulcers, the main risks depend of two things: the duodenal fistula and the ulcerous recurrence. Duodenal stump disruption has not specific causes and as well as in all the Billroth II resections may results from less than satisfactory duodenal closure. This complication was noted in one patient. Concerning the risk of the anastomotic ulcer, it is particularly increased in the Billroth II-Roux gastrectomy compared with the other types of gastric resections. When the operation is unaccompanied by vagotomy, the risk has maximum values. In this clinical material the ulcerous recurrence was noted in four patients.

Adult↗
PubMed1986

[Secondary malignancies after gastrectomy for gastric cancer].

In patients who have undergone gastrectomy for gastric cancer, the use of adjuvant chemotherapy has now become very widespread in Japan. The possibility of secondary malignancies in these patients emerges as a long-term effect of these therapeutic agents. This collaborative study was done to examine the possibility of secondary malignancies resulting from both operative methods and anticancer agents at the surgical departments of seven major institutions in Japan. The study was carried out using questionnaires for all patients with gastric cancer who had undergone gastrectomy between 1960 and 1975 in those hospitals and who had survived more than one year after gastrectomy. A total of 235 secondary malignancies (2.32%) were noted among 10,138 gastrectomized patients, and 22 cancers of the gastric remnant (0.29%) were recorded among 7,672 subtotal gastrectomized cases. Cancers suspected to be recurrent gastric cancer were all excluded. As to anticancer agents, Mitomycin C (MMC), 5-Fluorouracil (5-FU) or Tegafur and Cyclophosphamide (EDX) were analyzed. The occurrence rate of secondary cancers in gastric cancer patients was calculated in many instances by dividing the actual number of secondary cancers by the total time at risk (person-years). Patients with gastric cancer who had undergone gastric resection revealed a lower incidence of secondary malignancies than had been expected. The most common secondary cancers were those occurring in the digestive system, followed by those of the respiratory system. With regard to MMC, 67 secondary cancers (2.21%) occurred in the MMC group and 168 cancers (2.36%) in the non-MMC group. Although the overall incidence of secondary cancers showed no difference between MMC and non-MMC groups, secondary cancers of the digestive system were less common in the MMC group than in the non-MMC group. A total of 22 cancers originated in the gastric remnant out of 7,672 subtotally resected stomachs. The interval between the first operation and cancer of the gastric remnant varied greatly without showing any detectable trend. Nine cancers were observed to involve the anastomotic site while 14 did not involve the anastomotic site. The incidence of cancer of the gastric remnant tended to be slightly higher with the Billroth II method than in the Billroth I method, but there was no difference in the site of secondary malignancy between the two groups.

Adult↗
PubMedDate not supplied

Lack of body iron after total gastrectomy for adenocarcinoma of the stomach: a serum ferritin follow-up.

The postoperative evaluation over two years of body iron stores by measurement of serum ferritin concentrations in 43 patients who underwent total gastrectomy, for adenocarcinoma of the stomach showed that more than 50% of the patients had depleted iron stores. The iron stores were often already depleted preoperatively and were only slightly reduced postoperatively according to the time since surgery. Total gastrectomy produced an acute and significant increase in subnormal, but not in normal or high, serum ferritin concentrations, for a period of three months. Some, although not all, patients presenting metastasis during follow-up showed an increase in serum ferritin concentrations. This study would indicate that empty iron stores are common in patients with adenocarcinoma of the stomach, that total gastrectomy produces an acute increase in subnormal serum ferritin values, but iron stores are not replaced during follow-up and that high serum ferritin concentrations are rarely seen in patients with adenocarcinoma of the stomach.

Adenocarcinoma↗
PubMed1985

[Effect of restoring duodenal continuity after total gastrectomy in the rat].

An experimental study in the rat compared efficacy of re-establishment or not of duodenal continuity during digestive reconstruction by Y loop after total gastrectomy. Results were evaluated as a function of growth rate in the two groups. Nutrition following gastrectomy in rats treated by this technique was significantly better than in the other rats. Similar findings have been reported in humans, suggesting that this procedure be used more frequently after total gastrectomy.

Animals↗
PubMed1984

[Nutritional management of the patients after total gastrectomy using total parenteral nutrition (TPN)].

In this study therapeutic effect of total parenteral nutrition (TPN) for the patients undergoing total gastrectomy was evaluated and following results were obtained. Both incidence and cure rate of anastomotic leakage after total gastrectomy had markedly improved, in spite of increased resection rate and curative operation for the patients with advanced gastric cancer by introducing TPN routinely to the nutritional management. It is important to maintain serum albumin level above 3.0 g/dl to give enough calories and protein (40-50 kcal/kg/day). TPN using a combined carbohydrate solution such as the ratio for glucose, fructose, xylitol (4: 2: 1) seems to have a beneficial effect on the patients with surgical diabetes status. It is suggested that serum albumin is a most promising parameter in nutritional assessment of the preoperative period. But in the early postoperative period, rapid turnover protein such as prealbumin might be more accurate parameter. TPN during chemotherapy as an adjunct to surgery leads to diminished morbidity, and possibly to prolonged survival time in the patients undergoing gastrectomy for gastric cancer.

Combined Modality Therapy↗