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PubMed1999

Evaluation by microdensitometry and dual energy X-ray absorptiometry of changes in bone metabolism after gastrectomy.

We used microdensitometry (MD) and dual energy X-ray absorptiometry (DXA) to evaluate impaired bone metabolism in 79 patients who had undergone gastrectomy. With MD, radiographs are simultaneously taken of the second metacarpal bone and an aluminum step-wedge, and the images were analyzed by computer. DXA was used to measure the bone mineral density of the second through fourth vertebrae and the estimated volumetric bone mineral density (EstVBMD) was assessed. Significant positive correlations were obtained between EstVBMD as determined by DXA and metacarpal index (MCI) (r = 0.413, P < 0.01), peak of the cortex (GSmax) (r = 0.362, P < 0.05), peak of the middle portion of the bone marrow (GSmin) (r = 0.412, P < 0.01), and metacarpal bone mineral density (mBMD) (r = 0.413, P < 0.01) as determined by MD. When EstVBMD was compared with MCI, GSmax, GSmin, and mBMD according to sex, age, type of operation, and interval after operation, generally similar trends were obtained. We conclude that the determination by MD of various indices of bone metabolism is useful in the diagnosis of osteopathy after gastrectomy.

Absorptiometry, Photon↗
PubMedDate not supplied

[Chronic diarrhea as late complication of partial gastrectomy].

The authors present a clinical case of a forty-nine-year-old man admitted to hospital because of a seven month history of diarrhoea. The patient had been submitted to partial gastrectomy twenty-two years ago due to peptic ulcer. The analytic study was compatible with malabsorption syndrome. The colonoscopic and radiological studies revealed the existence of two fistulas between the gastric-stump, the small intestine and the colon. The patient was submitted to surgery with resection of the fistulas and re-gastrectomy with trunk vagotomy and Roux-en-Y reanastomosis. The follow-up twelve months after surgery showed an asymptomatic subject with weight recovery who had resumed his professional activities without limitations.

Anastomosis, Roux-en-Y↗
PubMed2001

[Extended total gastrectomy: indications in the 3rd millennium].

BACKGROUND: Total extended gastrectomy (TEG) is indicated in the treatment of gastric cancer for necessity or to achieve an oncologic radicality. By this surgical treatment the stomach and other organs or a part of them involved by primitive tumor are removed. METHODS: The authors report a study about 15 patients, out of 116 cases of gastric cancer, operated by TEG between 1990-1998. The middle-age of this patients was 63 years (range 45-76) and their general conditions were good in 9 cases and not-good in 6. The postoperative total parenteral nutrition (TPN) was carried out in all the patients, while preoperatively only in the most compromised patients. The surgical treatments were: 2 TG (total gastrectomy)+splenecomy; 3 TG+splenectomy+pancreatic resection; 4 TG+splenectomy+pancreatic resection+distal esophageal resection; 1 TG+distal esophageal resection; 2 TG+atypic hepatic resection; 1 TG+ atypic hepatic resection+duodenum resection; 2 TG+large intestine resection. While 10 patients were operated on to obtain radicality, 5 patients had a palliative treatment. RESULTS: There was not perioperative mortality, but we have observed: one dehiscence of the duodenal stump and one pancreatic fistula treated with conservative therapy; one left subfrenic abscess treated with surgical therapy. The survival has been higher in the patients treated with radicality. On the basis of these cases, the authors consider: 1) the possibility to obtain radicality by TEG; 2) the gastric localizations more often associated to extravisceral neoplastic localization; 3) the role of extensive lymph node resection (III and IV level) to obtain oncological radicality or neoplastic reduction. CONCLUSIONS. On the basis of their personal experience and related literature, the authors conclude that TEG is indicated to: 1) obtain a better lymphadenectomy; 2) obtain an oncologic radicality; 3) reduce the neoplastic mass in order to facilitate adjuvant therapy; 4) avoid or treat neoplastic complications; 5) improve the quality of life.

Aged↗
PubMed2001

Hand-assisted laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer.

Recently, a minimally invasive operation for gastric malignancies has been advocated, and the laparoscopic operation is noted as a technique that raises the quality of life. We performed distal gastrectomy with regional lymph node dissection by hand-assisted laparoscopic surgery for 60 cases of gastric cancer located in the middle or lower third of the stomach. Billroth I reconstruction was applied intracorporeally to the first 30 cases by using the double stapling method with a conventional circular stapling device, and in the final 30 cases, the quadrilateral (square) stapling technique with a laparoscopic linear stapling device was used to prevent postoperative anastomotic bleeding. This technique not only is less invasive, but also is similarly curative compared with open gastrectomy that was performed for 60 gastric cancer cases of similar staging before the beginning of this procedure.

Adult↗
PubMedDate not supplied

A novel operative technique on proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter.

BACKGROUND/AIMS: This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter. METHODOLOGY: We have performed a new technique for reducing postgastrectomy sequelae such as reflux esophagitis, early dumping syndrome, and microgastria in early gastric cancer located in the proximal third of the stomach. The technique consists of proximal gastrectomy with preservation of the hepatic, pyloric, celiac branch of the vagal nerve, and abdominal esophagus (lower esophageal sphincter), and reconstruction by interposition of a jejunal J pouch. To reserve pyloric function, pyloroplasty can be omitted by preservation of the pyloric branch from the vagal nerve. To restore loss of reservoir function, the reconstruction is performed with an interposed jejunal J pouch. Sacrifice of the mesenteric arcades is kept to a minimum to preserve the autonomic nerve and blood flow in the mesentery. RESULTS: All of the patients who underwent this operation were able to eat an adequate amount of food at 6 months after surgery and they were satisfied with their postoperative status. And that, we have not experienced postgastrectomy disorders such the dumping syndrome and reflux esophagitis. CONCLUSIONS: Therefore, this method is useful for preventing the postoperative disorders in patients with early gastric cancer located in the proximal third of the stomach.

Adult↗
PubMedDate not supplied

Factors influencing the development of small intestinal obstruction following total gastrectomy for gastric cancer: the impact of reconstructive route in the Roux-en-Y procedure.

BACKGROUND/AIMS: The factors influencing the development of small intestinal obstruction following gastric surgery are controversial. METHODOLOGY: Univariate and multivariate analyses were carried out on data from 48 patients with gastric cancer who underwent total gastrectomy and Roux-en-Y reconstruction for a potential cure. RESULTS: Of these 48 patients, 11 (22.9%) presented with mechanical obstruction in the small intestine postoperatively. There were no statistically significant differences with regard to age, sex, and the presenting pathology. The development of obstruction was not related to a longer operation time, a greater estimated blood loss during surgery, an extensive lymph node dissection and a combined resection of adjacent organs. The probability that the antecolic anastomosis would cause obstruction was significant when compared with findings in case of the retrocolic anastomosis (P < 0.05). In the multivariate logistic regression analysis, the significant risk factors related to the development of small intestinal obstruction proved to be reconstructive route of jejunal loop. CONCLUSIONS: In potentially curative patients undergoing total gastrectomy, retrocolic anastomosis should be attempted to prevent the development of postoperative intestinal obstruction.

Aged↗
PubMedDate not supplied

Postoperative morbidity and mortality after gastrectomy for gastric carcinoma.

BACKGROUND/AIMS: Surgical technique and postoperative care for gastric cancer have significantly improved in recent years. However, whether postoperative morbidity or mortality rates after gastrectomy for gastric cancer were reduced or not in recent years was unclear. In this study, we analyzed the chronological changes of postoperative morbidity and mortality rates, and we analyzed risk factors for postoperative morbidity and mortality in patients undergoing gastrectomy for carcinomas of the stomach. METHODOLOGY: A total of 887 patients with gastric cancer were gastrectomized in our hospital between January 1985 and December 1996. The patients were divided into three groups on the basis of chronology. The first group included patients treated over the period 1985 to 1988 (n = 324); the second group, 1989 to 1992 (n = 300); and the third group, 1993 to 1996 (n = 263). Postoperative morbidity rates and mortality rates were compared among the three groups. Also, significant risk factors affecting postoperative morbidity and in-hospital mortality were analyzed by the multiple logistic regression analysis. RESULTS: Postoperative complications were detected in 95 patients (10.7%) and in-hospital mortality rate was 2.4% (21/887). Postoperative morbidity rates were 10.5%, 11%, and 10.6% in the first, second, and third groups, respectively and postoperative mortality rates were 2.5%, 2%, and 2.7%, respectively. These postoperative morbidity and mortality rates were not different between the groups (P = 0.979 and P = 0.866). The most common postoperative complication was anastomotic leakage (56/95, 58.9%). Significant risk factors affecting in-hospital mortality were Stage IV (P = 0.006) and noncurative gastric resection (P = 0.004). However, the extent of lymph node dissection, combined resection, or the existence of preoperative complications were not significant risk factors of in-hospital mortality by multiple logistic regression analysis. CONCLUSIONS: These results indicate that patients with far-advanced gastric cancer might have a high risk of postoperative mortality. In noncurative operations for patients with advanced gastric cancer, unnecessary lymph node dissection or combined resection should be avoided.

Adult↗
PubMedDate not supplied

An experimental study of jejunal pouch replacements following total gastrectomy.

BACKGROUND/AIMS: The nutritional effects of pouch replacement after total gastrectomy remain clinically controversial. Two previous experiments failed to show any nutritional benefit. However, the pouches applied clinically and examined experimentally so far were all of anti-peristaltic type. METHODOLOGY: Male 7- or 8-week-old Wistar rats were divided into 3 experimental groups after total gastrectomy. For group 1 and 2 rats, Roux-en-Y reconstructions and Hunt-Lawrence pouches, i.e., anti-peristaltic type, were performed, respectively. Group 3 rats underwent a new type of iso-peristaltic pouch replacement. Food intake was recorded daily and all rats were weighed once a week. At the end of the 12-week experimental period, there were 9 rats in group 1, 10 in group 2, and 8 in group 3. The volumes of the gastric reservoirs were measured, and blood samples were taken. Five 20-week-old rats served as control of weight, food intake, and laboratory data. RESULTS: The volumes of the gastric reservoirs in group 2 and 3 rats were significantly larger than in group 1 animals. However, there were no intergroup differences in weight change or food intake. The weights and the food intakes of the 3 experimental groups were significantly lower than those of the control rats. No superiority in the results of blood samples was observed among the experimental groups. Correlations between weight gain and food intake were shown in all groups. But, a correlation between the volume of the gastric reservoir and food intake was observed only for group 3 rats. CONCLUSIONS: The present study showed no nutritional benefits of an iso- as well as an anti-peristaltic pouch replacement.

Animals↗
PubMedDate not supplied

Billroth I versus Billroth II versus Roux-en-Y after subtotal gastrectomy. Prospective [correction of prespective] randomized study.

BACKGROUND/AIMS: The aim of this study was to evaluate functional results after Billroth I, Billroth II and Roux-en-Y reconstruction in subtotal gastrectomy. METHODOLOGY: Forty-five patients were randomized between 1990 and 1995 and stratified in 3 different groups: 15 BI, 15 BII and 15 Roux. They were investigated by esophagogastroduodenoscopy with multiple biopsies and upper gastrointestinal scintiscanning, to evaluate gastroesophageal reflux and dynamics of gastric emptying. They also answered a questionnaire: Gastrointestinal Quality of Life. Index. RESULTS: A reflux esophagitis was found in 5 BI, in 7 BII and in 2 Roux (p < 0.001). No gastric lesions were found in 6 BI, in 5 BII and in 12 Roux, (BI vs. Y, p < 0.05; BII vs. Y, p < 0.001). Chronic superficial gastritis was present in 9 BI, in 4 BII and in 3 Roux (BI vs. Y, p < 0.05). Dynamic scintiscan demonstrated the presence of gastroesophageal reflux in 5 BI and gastric emptying was fast (37' < T 1/2 < 86'), but incomplete (60' residual activity: 49-62%). Gastroesophageal reflux was evident in 7 BII with slow (28' < T 1/2 < 143') and incomplete (60' residual activity: 48-72%) gastric emptying. Gastroesophageal reflux was detected in 2 Roux and radioactive bolus progression in the Roux limb was fast (24' < T 1/2 < 53') and complete (60' residual activity: 42-52%) (BI vs. Y; BII vs. Y, p < 0.001). There was no statistical significance between Gastrointestinal Quality of Life Index score in the 3 groups. CONCLUSIONS: The Authors affirm that Roux-en-Y is the technique of choice in subtotal gastrectomy, if compared with BI and BII.

Adult↗
PubMed2002

[Benefit of screening for gastric cancer--a comparison of symptomatic and screened patients who underwent gastrectomy].

UNLABELLED: We compared the clinicopathological factors and treatment results with regard to symptoms and screening in patients who underwent gastrectomy for primary gastric cancer. PATIENTS: The subjects included 797 patients with asymptomatic gastric cancer (SCG) and 1090 patients with symptomatic cancer (SYG) who had undergone gastrectomy for gastric cancer from 1989 to 2000. RESULTS: The proportion of early gastric cancer, N0 cases, and curative cases in the SCG and SYG patients were 70% & 33%, 77% & 44%, and 98% & 80%, respectively (p = 0.000, for each). Five-year survival rates of the SCG and SYG patients were 87% and 63% (p = 0.000). CONCLUSION: Screening for gastric cancer in order to detect asymptomatic disease may contribute to patient survival.

Adult↗
PubMed2002

[Early enteral nutrition in cancer patients subjected to a total gastrectomy].

BACKGROUND: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. AIM: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus. PATIENTS AND METHODS: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. RESULTS: Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. CONCLUSIONS: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.

Aged↗
PubMed2002

Reconstruction after total gastrectomy.

After total gastrectomy it is necessary to realize the reconstruction of the upper part digestive tract. It is necessary to choose the reconstruction method, which provides good life quality, and extensive physiologic regulation of gastrointestinal hormones after total gastrectomy. There is no ideal reconstruction method. Nowadays there are about 70 kinds of reconstruction methods. It is very important to preserve the duodenal passage. Also the production of reservoir is important. The conclusions of studies are not homogeneous. The patients can benefit from the reconstruction preserving duodenal passage and formed by pouch. (Fig. 1, Ref. 23.).

Animals↗
PubMed2002

[Y Roux anastomosis of small intestine in gastrectomy and esophagectomy].

A clutch-like method of esophagojejunal anastomosis on the excluded by the Roux method loop of the small intestine was worked out in experiments on 80 corpses of humans. It was found that the anastomosis should be made at a distance of 3.2 +/- 0.48 cm (two diameters of the patient's esophagus) from the tightly sutured part of the small intestine. In the clinic there were no cases of incompetence of the anastomosis sutures in 86 gastric cancer patients aged from 31 to 71 years (81 gastrectomies and 5 extirpations of the gastric stump). Two patients died (2.3%). The follow-up of the patients during 1-10 years after operation has found that mild reflux-esophagitis developed in 6.1% of the patients, average degree--in 2.04%. No cicatricial strictures of the anastomosis were revealed. The method was used in 6 patients in gastroplasty after Kupriyanov-Zakharov. The dumping syndrome of mild degree developed in 23.6%, average--in 2.7% of the patients. The anastomosis can be used in gastrectomy as a method of choice in extirpation of the gastric stump.

Adult↗
PubMedDate not supplied

[Stapled esophago-jejunal anastomosis after total gastrectomy in gastric neoplasm].

A number of 1031 patients with gastric cancer have been admitted in the First Surgical Clinic of Iasi between 1986-2001. The operability index was 86%, 52% being resectable and 36% having potential curative resection. In this group, 222 patients benefited from total gastrectomies. We consider the introduction of stapled eso-jejunal anastomosis (38 patients) as the most important moment in this development, as the manual performance anastomosis is considered difficult due to the problems imposed by suturing in a deep space. Postoperative course of patients who benefited from stapled anastomosis was simple although many patients had a poor biological status. We encountered only one small fistula, which was dealt with conservative. Patients in this group had immediate postoperative results significantly better than the comparative group with manually performed anastomosis. Introduction of stapler techniques increased the proportions of patients who benefited from palative total gastrectomies for advanced gastric cancer. We consider that a method to solve the frequent complications, insured an increased intraoperative comfort, reduced the number of postoperative complications, increased survival and improved patients quality of life.

Adult↗
PubMed2003

[An economic evaluation on the clinical pathway for gastrectomy].

OBJECTIVE: To analyze the costs of gastrectomy patients treated with the clinical pathway. PATIENTS AND METHODS: Seventy-six patients (path group 44, control 32) had undergone gastrectomy in our hospital in 2001. The clinical pathway included the same care map. Treatment costs were estimated from medical cost receipt data. The economical analysis was performed from the point of the direct cost payer's view. RESULTS: The length of hospital stay in the path group was 27.1 +/- 5.9 days and decreased 8.3 days in comparison with the control(p < 0.001). The cost of the path group was 145.290 +/- 23.773 points and 19.278 points less than the control(p < 0.005). In the path group the operation case per bed was increased 30% and the cost per bed was also increased 15% more than the control. CONCLUSIONS: The implementation of the clinical pathway decreased the length and the cost of hospital stay. The clinical pathway is effective to use the hospital resources, such as bed.

Costs and Cost Analysis↗
PubMedDate not supplied

Survival benefit of palliative gastrectomy in advanced incurable gastric cancer.

To identify adequate surgical strategies for patients with incurable gastric cancer, long-term results in 228 patients with peritoneal metastasis were analyzed. There was a significant difference in survival between the 141 palliatively gastrectomized and the 87 non-gastrectomized patients. The prognostic factor both in all patients and in gastrectomized patients was the degree of peritoneal metastasis (hazard ratio 1.9073/1.2530) but none was selected in those not gastrectomized. In patients with slight peritoneal metastases (POCY1, P1), the prognostic factors were resection (hazard ratio 5.8631) and a tumor diameter less than 100 mm (hazard ratio 1.7762), but there were non where severe peritoneal metastases were present (P2, P3). Morbidity was frequent in palliation. Palliative gastrectomy is indicated in POCY1 or P1 cases with tumor diameters less than 100 mm. In such gastrectomy, lymph node dissection is limited to a little more than D1, which eradicates only macroscopically identifiable metastatic lymph nodes near the stomach.

Aged↗
PubMedDate not supplied

Afferent loop obstruction with pancreatitis after distal partial gastrectomy with B-II reconstruction added Braun anastomosis for cancer of the stomach.

Afferent loop obstruction after distal gastrectomy is rare. We present a case of a 59-year-old women who underwent distal partial gastrectomy with Billroth-II reconstruction added Braun anastomosis for cancer of the stomach. On the 10th postoperative day, she had high-grade fever and complained of abdominal pain. We diagnosed the afferent loop obstruction by computed tomography scan. Re-operation was performed to decompress the afferent loop. New Braun anastomosis was created, but because the decompression of the biliary tract was insufficient, percutaneous transhepatic biliary drainage was performed on the 52nd post-operative day. Her clinical course subsequently improved and she was discharged on the 104th postoperative day. This paper describes the details of this unusual condition, and we discuss a review of the literature.

Acute Disease↗
PubMed2003

[A prospective randomized study on the method of reconstruction after total gastrectomy].

OBJECTIVE: To find an ideal reconstruction method after total gastrectomy. METHODS: With 12 healthy persons as control, a total of 120 gastric cancer patients received their digestive tract reconstruction after total gastrectomy were randomized into Roux-en-y esophagojejunostomy group (A), P pouch with Roux-en-y esophagojejunostomy group (B), Hunt-Lawrence esophagojejunostomy group (C), and jejunal interposition esophagojejunostomy group (D). After operation, quality of life, prognosis nutrition index (PNI), body weight, serum nutritional parameters, gastrointestinal hormone level and immunological state were evaluated. RESULTS: The quality of life, PNI, body weight and serum nutritional parameters (SI, TS and Hb) were better in group D than those in groups A, B and C (P < 0.05). The cholecystokinin (CCK) level and NK cell, CD(4)(+) cell, CD(8)(+) cell and CD(4)/CD(8) ratio in group D, being similar to the control group, were significantly higher than groups A, B and C (P < 0.05). CONCLUSION: Modified jejunal interposition esophagojejunostomy is a reasonable reconstruction method. The construction of "P" pouch, reserving foods as the stomach, can preserve the duodenal passage and secretion of the gastrointestinal hormones, which results in better digestion of the food and absorption of the nutrients. This method simplifies the operation and guarantee the blood supply of interpositioned jejunum without causing ischemia at the anastomotic orifice.

Esophagus↗