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McVeay C, Davis CA, Thompson SK. Pancreatic insufficiency after gastrectomy: an underdiagnosed condition? ANZ J Surg 2024; 94:1674-1675. [PMID: 39155470 DOI: 10.1111/ans.19204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/04/2024] [Indexed: 08/20/2024]
Affiliation(s)
- Christina McVeay
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
- Division of Surgery, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Caitlin A Davis
- Department of Dietetics and Nutrition, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sarah K Thompson
- Division of Surgery, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Gastrointestinal Specialists, Adelaide, South Australia, Australia
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Li Z, Dong J, Huang Q, Zhang W, Tao K. Comparison of three digestive tract reconstruction methods for the treatment of Siewert II and III adenocarcinoma of esophagogastric junction: a prospective, randomized controlled study. World J Surg Oncol 2019; 17:209. [PMID: 31810484 PMCID: PMC6898954 DOI: 10.1186/s12957-019-1762-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/26/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The incidence of adenocarcinoma of esophagogastric junction (AEG) has recently risen worldwide, including in Eastern Asia. The aim of the study was to explore the short-term and long-term clinical efficacy of piggyback jejunal interposition reconstruction single-tract reconstruction (PJIRSTR), piggyback jejunal interposition reconstruction double-tract reconstruction (PJIRDTR), and total gastrectomy esophageal jejunal Roux-en-Y anastomosis (TGRY) for the treatment of Siewert II and III AEG patients. METHODS A total of 300 Siewert II and III AEG patients admitted to Shanxi Tumor Hospital from June 2015 to December 2017 were prospectively selected. Patients were randomly divided into PJIRSTR group (n = 98), PJIRDTR group (n = 103), and TGRY group (n = 99) using the random number table method. RESULTS There were no statistically significant differences in total operation time, intraoperative blood loss, time of first anal exhaust, and postoperative hospital stay among the three groups (F = 2.526, 0.457, 0.234, 0.453; P > 0.05). The reconstruction time of PJIRSTR group and PJIRDTR group was longer than that of TGRY group (P < 0.01). There were no significant differences in cases of anastomotic leakage, anastomotic bleeding, abdominal infection, incision infection, ileus, and dumping syndrome in three groups (P > 0.05). The incidence of reflux esophagitis at 3, 6, 12, and 18 months after surgery in the PJIRSTR group and the PJIRDTR group were significantly lower than TGRY group in the same period (P < 0.05). Compared with PJIRDTR group and TGRY group, PJIRSTR group had a small fluctuation range of postoperative nutrition indexes and had basically recovered to the preoperative level at 18 months. Four patients of Visick grade IV presented in TGRY group 18 months postoperatively, which was significantly higher compared with the other two groups. CONCLUSION Compared with PJIRDTR and TGRY, PJIRSTR can significantly reduce the incidence of postoperative reflux esophagitis and improve the long-term nutritional status of patients. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-IIR-16007733. Registered 07 November 2015 - Retrospectively registered, http://www.chictr.org.cn/searchproj.aspx.
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Affiliation(s)
- Zhiguo Li
- Department of Minimal Invasive Digestive Surgery, Shanxi Tumor Hospital, Shanxi Medical University, Taiyuan, 030013, China
| | - Jianhong Dong
- Department of Minimal Invasive Digestive Surgery, Shanxi Tumor Hospital, Shanxi Medical University, Taiyuan, 030013, China.
| | - Qingxing Huang
- Department of Minimal Invasive Digestive Surgery, Shanxi Tumor Hospital, Shanxi Medical University, Taiyuan, 030013, China
| | - Wanhong Zhang
- Department of Minimal Invasive Digestive Surgery, Shanxi Tumor Hospital, Shanxi Medical University, Taiyuan, 030013, China
| | - Kai Tao
- Department of Minimal Invasive Digestive Surgery, Shanxi Tumor Hospital, Shanxi Medical University, Taiyuan, 030013, China
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3
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Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 2017; 23:7059-7076. [PMID: 29093615 PMCID: PMC5656454 DOI: 10.3748/wjg.v23.i39.7059] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 05/27/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases (diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin (CCK); celiac or inflammatory bowel disease (IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery (asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy (PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI (66%-92%). EPI occurs in patients with type 1 (26%-57%) or type 2 diabetes (20%-36%) and is typically mild to moderate; by definition, all patients with type 3c (pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease (4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD (14%-74%) and up to 100% of gastrointestinal surgery patients (47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Mark E Haupt
- Medical Affairs, AbbVie Inc., North Chicago, IL 60064, United States
| | - David E Geller
- Cystic Fibrosis Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
| | - Jerry A Hall
- CREON® Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
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4
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Kim J, Kim S, Min YD. Consideration of cardia preserving proximal gastrectomy in early gastric cancer of upper body for prevention of gastroesophageal reflux disease and stenosis of anastomosis site. J Gastric Cancer 2012; 12:187-93. [PMID: 23094231 PMCID: PMC3473226 DOI: 10.5230/jgc.2012.12.3.187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 07/15/2012] [Accepted: 07/30/2012] [Indexed: 12/12/2022] Open
Abstract
Purpose The aim of this study is to evaluate the feasibility and safety of cardia preserving proximal gastrectomy, in early gastric cancer of the upper third. Materials and Methods A total of 10 patients were diagnosed with early gastric cancer of the upper third through endoscopic biopsy. The operation time, length of resection free margin, number of resected lymph nodes and postoperative complications, gastrointestinal symptoms, nutritional status, anastomotic stricture, and recurrence were examined. Results There were 5 males and 5 females. The mean age was 56.5±0.5 years. The mean operation time was 188.5±0.5 minutes (laparoscopic operation was 270 minutes). Nine patients were T1 stage (T2 : 1), and N stage was all N0. The mean number of resected lymph nodes was 25.2±0.5. The length of proximal resection free margin was 3.1±0.1 cm and distal was 3.7±0.1 cm. Early complications were surgical site infection (1), bleeding (1), and gastro-esophageal reflux disease (1) (this symptom was improved with medication). Late complications were dyspepsia (3) (this symptom was improved without any treatment), and others were nonspecific results of endoscopy or symptom. Conclusions Cardia preserving proximal gastrectomy was feasible for early gastric cancer of the upper third. Further evaluation and prospective research will be required.
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Affiliation(s)
- Jihoon Kim
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
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5
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Paik CN, Choi MG, Lim CH, Park JM, Chung WC, Lee KM, Jun KH, Song KY, Jeon HM, Chin HM, Park CH, Chung IS. The role of small intestinal bacterial overgrowth in postgastrectomy patients. Neurogastroenterol Motil 2011; 23:e191-6. [PMID: 21324050 DOI: 10.1111/j.1365-2982.2011.01686.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) is expected in postgastrectomy patients; however, its role has not been clarified. This study was to estimate the prevalence of SIBO and investigate the clinical role of SIBO in postgastrectomy patients. METHODS This prospective study involved 76 patients who underwent gastrectomy for early gastric cancer with no evidence of recurrence. An H(2)-CH(4) breath test with oral glucose challenge test was performed to diagnose SIBO and dumping syndrome. Sigstad dumping questionnaires, serum glucose, hematocrit and pulse rate were simultaneously monitored for every 30 min for 3 hours. KEY RESULTS There were significant differences in SIBO between the postgastrectomy patients and controls (77.6%vs 6.7%, P < 0.01). Abdominal fullness or borborygmus during oral glucose load were more common in SIBO-positive than in negative patients (50.8%vs 17.6%, P = 0.03), and were the independent factors for predicting SIBO in postgastrectomy patients (P = 0.02). The prevalences of dumping syndrome and hypoglycemia after oral glucose were 35 (46.1%) and 19 (25.0%), and were not different between both groups. However, the plasma glucose was significantly lower in SIBO-positive than in SIBO-negative patients at 120 and 150 min after oral glucose load (P < 0.05). No significant differences were observed in pulse rate and hematocrit in both groups. CONCLUSIONS & INFERENCES SIBO is common among postgastrectomy patients. It appears to be associated with postprandial intestinal symptoms and might aggravate late hypoglycemia. SIBO could be a new therapeutic target for managing intestinal symptoms in postgastrectomy patients.
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Affiliation(s)
- C N Paik
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
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6
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Kwag SJ, Jung SH, Lee YJ, Jung CY, Park ST, Choi SK, Hong SC, Jung EJ, Joo YT, Ha WS. The Risk Factors of Reflux Complication after Gastrectomy for Proximal Gastric Cancer. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.79.4.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Seung-Jin Kwag
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Sang-Ho Jung
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Young-Jun Lee
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Chi-Young Jung
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Soon-Tae Park
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Sang-kyeong Choi
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Soon-Chan Hong
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Eun-Jung Jung
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Young-Tae Joo
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Woo-Song Ha
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
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Abstract
BACKGROUND Gastric pouches have the potential to improve nutrition following total gastrectomy, compared with standard reconstruction. However, a consensus view of clinical benefit is not available, at least partly due to a lack of standardization of pouch design or size. This study was undertaken to identify optimal conditions for pouch design. METHODS A mathematical model was established and a porcine model constructed to evaluate the pressure/volume dynamics of the pouch. A "J" pouch was constructed at anastomotic lengths of 5, 10, 15, and 20 cm. Each pouch was distended with saline and the pressure/volume relationship established. RESULTS Mathematically, increasing the anastomotic length of the pouch to 15 cm increases the volume significantly; thereafter, there is minimal benefit of increasing the pouch length further. For smaller pouches (5 and 10 cm) a 350-to 400-ml volume (approximate meal volume in the elderly) is never achieved until higher pressures (45 cmH(2)O) are applied. However, in the larger pouches (15 and 20 cm) a 350-to 400-ml volume is readily achieved at basal pressures of 15 cmH(2)O. CONCLUSION Smaller pouches never achieve adequate volumes at basal pressures; accordingly, it is unlikely that they will lead to any clinical benefit. Further in-vivo studies should therefore be based upon 15-cm pouch designs.
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Abstract
The stomach has a variety of functions that are lost with gastrectomy. Since nowadays a significant number of patients are long-term survivors, consequences of this loss need to be considered by gastroenterologists and surgeons alike. Abnormal transit, disturbed general nutrition and micronutrient deficiencies are the most common problems. The main resulting symptoms are early and late dumping, reflux esophagitis, weight loss, anemia, and osteopathy. It is not definitively clear if pouch reconstruction can really improve the situation. Dietary measures, rarely re-operation, and in particular adequate follow-up of metabolic and nutrition parameters with consequent substitution are the main therapeutic necessities.
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Affiliation(s)
- Jürgen Schölmerich
- Department of Internal Medicine I, University Medical Center Regensburg, D-93042 Regensburg, Germany.
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9
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Qin XY, Lei Y, Liu FL. Effects of two methods of reconstruction of digestive tract after total gastrectomy on gastrointestinal motility in rats. World J Gastroenterol 2003; 9:1051-3. [PMID: 12717854 PMCID: PMC4611370 DOI: 10.3748/wjg.v9.i5.1051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of Roux-en-Y and jejunum interposition reconstruction procedures after total gastrectomy on intestinal motility.
METHODS: Fifty male Sprague-Dawley rats were randomly divided into 5 groups: the control group (C), the laparotomy group (L), the jejunal transection group (JT) where the jejunum was transected 10 cm distal from the Treitz ligament and anastomosed, the Roux-en-Y group (RY) and the jejunal interposition group (JI) after total gastrectomy. To evaluate intestinal transit, the animals were given 0.1 ml Evans Blue solution through an orogastric tube. The rats were executed by CO2 inhalation 30 minutes later and the intestinal transmit was determined as the distance between the site of esophageojejunal anastomosis and the most distal site of small intestine colored with blue.
RESULTS: One month after operation, the body weight of rats among JI and RY were almost identical (274.6 ± 9.5 vs 270.4 ± 10.6, P > 0.05), but were significantly lighter than those of JT and L group. Four months after the operation, the body weight in the JI group increased compared to the preoperative level (345.2 ± 15.7 g vs 299.5 ± 8.3 g, P < 0.01). However, the body weight of RY group decreased compared to preoperative (255.1 ± 11.3 g vs 295.0 ± 12.0 g, P < 0.01). The difference was more significant at six months postoperative. Small bowel transmit time in RY was slower than that in JI group and C group (P < 0.01).
CONCLUSION: Changes of body weight and intestinal motility in JI group are less influenced than in RY group.
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Affiliation(s)
- Xin-Yu Qin
- Department of General Surgery, ZhongShan Hospital, Fudan University, Shanghai 200032, China.
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10
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Liedman B. Symptoms after total gastrectomy on food intake, body composition, bone metabolism, and quality of life in gastric cancer patients--is reconstruction with a reservoir worthwhile? Nutrition 1999; 15:677-82. [PMID: 10467612 DOI: 10.1016/s0899-9007(99)00123-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Gastric cancer is worldwide one of the most common causes of cancer death. Operation is the only treatment at this time that cures some patients. The side effects of the operation are, however, considerable, and include postoperative weight loss, loss of appetite, and other metabolic and nutritional changes. The recovery is very slow and incomplete. Reconstruction with different types of pouches has been asserted to facilitate the nutritional recovery, but results from different studies are somewhat contradictory. Malnutrition, osteoporosis, osteomalacia, and impaired quality of life are often but not always described. We can, however, establish that after a total gastrectomy, gastric cancer patients are very much at risk for these complications, which are probably caused by impaired food intake and steathorrhea even when the patients are cured from their cancer disease. In order to minimize the nutritional problems, it is crucial to avoid anastomotic narrowing and bile reflux. Roux-en-Y reconstruction seems to be the method of choice. Evidence from several randomized studies now speak in favor of including some type of pouch in the reconstruction. The most commonly used pouch today is the jejunal J-pouch. How the effect is exerted is not clear. Probably both the reservoir function of the pouch and changes in intestinal transit time are important. The importance of nutritional surveillance of these patients should not be underestimated, and most of the observed differences from various reports are probably due to dissimilarity in the follow-up protocols. A patient surviving his/her cancer has a decreased risk of developing severe disturbances in bone metabolism, food intake, body composition, and quality of life if the patient is under concerned nutritional surveillance and reconstructed with a pouch.
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Affiliation(s)
- B Liedman
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
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11
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Iivonen MK, Ahola TO, Matikainen MJ. Bacterial overgrowth, intestinal transit, and nutrition after total gastrectomy. Comparison of a jejunal pouch with Roux-en-Y reconstruction in a prospective random study. Scand J Gastroenterol 1998; 33:63-70. [PMID: 9489910 DOI: 10.1080/00365529850166220] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Jejunal pouches after total gastrectomy have been introduced to diminish postgastrectomy symptoms and improve nutrition. However, the effect of a pouch on the intestinal bacteriology and transit is controversial. METHODS Bacterial overgrowth was measured with the glucose breath test and the mouth-to-caecum transit time (MCT) by means of the lactulose breath test after total gastrectomy and Roux-en-Y reconstruction in 24 patients with a pouch (Pouch group) and in 22 patients without a pouch (Roux-en-Y group). Postoperative symptoms were evaluated with a standard questionnaire, and nutrition was measured by blood chemistry and weight loss. RESULTS MCTT was 110 +/- 44 min in the Roux-en-Y group and 117 +/- 44 min in the Pouch group (NS). Eighty-six per cent of the patients in the Roux-en-Y group and 91% of the patients in the Pouch group had bacterial overgrowth (NS). Transit time was shorter in patients with severe dumping than patients without dumping (60 +/- 28 min versus 115 +/- 41 min; P = 0.04). Maximal hydrogen concentration in the glucose breath test correlated negatively with serum albumin and iron concentrations and with postoperative weight loss, and positively with serum alkaline phosphatase activity. CONCLUSIONS Bacterial overgrowth is common in the upper intestine after total gastrectomy. Pouch reconstruction does not delay the transit of liquids. Bacterial overgrowth may be one of the main aetiologic factors in postgastrectomy malnutrition.
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Affiliation(s)
- M K Iivonen
- Dept. of Surgery and Clinical Physiology, Tampere University Hospital, Finland
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12
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Nakane Y, Akehira K, Okumura S, Okamura S, Boku T, Okusa T, Hioki K. Jejunal pouch and interposition reconstruction after total gastrectomy for cancer. Surg Today 1997; 27:696-701. [PMID: 9306581 DOI: 10.1007/bf02384979] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The authors modified the operative procedures used in pouch and interposition (PI) reconstruction in an attempt to improve the surgical results after total gastrectomy, because a randomized controlled trial had revealed that the clinical assessment of PI was quite poor, even though it is a physiological route. In most of the treated patients, the gastric emptying test revealed delayed emptying, and an X-ray video film showed folding and twisting of the jejunal conduit between the pouch and duodenum, which disturbed the transmission of nutrition. Modified PI (m-PI) was performed by decreasing the length of the jejunal conduit and widening the mesenteric pedicle to preserve the blood and nerve supply. This procedure was retrospectively compared with the previously used PI reconstruction by evaluating the postprandial symptoms, food intake, body weight, serum nutritional parameters, and emptying time of the gastric substitute. The m-PI group (n = 6) showed a lower incidence of symptoms, a greater food intake, and a greater weight recovery than the PI group (n = 6). The gastric emptying test also revealed an acceptable degree of emptying. We thus conclude that the m-PI reconstruction is more useful for improving the postoperative quality of life than the previously used method of PI reconstruction.
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Affiliation(s)
- Y Nakane
- Second Department of Surgery, Kansai Medical University, Osaka, Japan
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13
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Abstract
Enterocutaneous and aortoenteric fistulas arise from a diverse array of pathophysiologic states. Classification by anatomic, physiologic, and etiologic systems is critical to both nonoperative and operative treatment planning.
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Affiliation(s)
- S M Berry
- Department of Surgery, University of Cincinnati, Ohio, USA
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14
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Liedman B, Andersson H, Berglund B, Bosaeus I, Hugosson I, Olbe L, Lundell L. Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir. Br J Surg 1996; 83:1138-43. [PMID: 8869329 DOI: 10.1002/bjs.1800830835] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.
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Affiliation(s)
- B Liedman
- Department of Surgery, University of Gothenburg, Sweden
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15
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Fuchs KH, Thiede A, Engemann R, Deltz E, Stremme O, Hamelmann H. Reconstruction of the food passage after total gastrectomy: randomized trial. World J Surg 1995; 19:698-705; discussion 705-6. [PMID: 7571666 DOI: 10.1007/bf00295908] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Controversial results have been reported regarding the importance of the duodenal food passage after total gastrectomy. There are a number of experimental and clinical studies showing an advantage for the jejunal interposition between esophagus and duodenum. Others favor the Roux-en-Y reconstruction, as it is technically less demanding. The purpose of this study was the randomized comparison between two major reconstruction principles after total gastrectomy for gastric cancer (i.e., jejunal interposition with pouch versus Roux-en-Y pouch reconstruction). A group of 120 patients with gastric cancer were randomized and operated on during a 5-year period according to standardized operative protocols, using either a jejunal interposition with pouch (JIP) or the Roux-en-Y reconstruction with pouch (RYP). Endpoints of this study were operation time, intra- and postoperative problems and complications, patients' body weight, functional assessment, and quality of life. Of the 120 patients, 14 had to be withdrawn during the operation because only the Roux-en-Y reconstruction was technically possible. Finally, 53 patients with JIP were compared with 53 patients with RYP for the perioperative course. There were no significant differences between the two procedures (RYP and JIP) regarding complications (24.5% and 26.4%, respectively), mortality (3.8% and 1.9%, respectively), and operation time (4.35 hours and 4.40 hours, respectively). For long-term functional comparison 46 (RYP, n = 26; JIP, n = 20) patients were without recurrence after 3 years of survival. Comparison of body weight, Visick scoring, and the Spitzer Index also did not reveal any significant difference between the two operation methods.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K H Fuchs
- Department of Surgery, University of Würzburg, Germany
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16
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Nakane Y, Okumura S, Akehira K, Okamura S, Boku T, Okusa T, Tanaka K, Hioki K. Jejunal pouch reconstruction after total gastrectomy for cancer. A randomized controlled trial. Ann Surg 1995; 222:27-35. [PMID: 7618964 PMCID: PMC1234751 DOI: 10.1097/00000658-199507000-00005] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The authors determined the optimum reconstruction procedure after total gastrectomy in terms of the quality of life of the patients. SUMMARY BACKGROUND DATA Gastric replacement with various enteric reservoirs has been used to improve the postprandial symptoms and nutrition of patients after total gastrectomy. However, the effect of each is uncertain because no prospective randomized studies have been conducted. METHODS A randomized controlled trial was conducted to compare the usefulness of the three reconstruction procedures of simple Roux-en-Y (RY; N = 10), pouch and Roux-en-Y (PR; N = 10), and pouch and interposition (PI; N = 10). In each subject, the postprandial symptoms, food intake in a single meal, body weight, serum nutritional parameters, and emptying time of the gastric substitute were evaluated. RESULTS The PR group showed significantly greater food intake in a single meal than the RY and PI groups, and greater weight recovery than the PI group. A gastric emptying test also revealed satisfactory retention capacity and emptying time of the gastric substitute in the PR group. CONCLUSIONS Pouch and Roux-en-Y reconstruction is the most useful of the three procedures for improving the postoperative quality of life. In patients with pouch and interposition reconstruction, the clinical assessment was quite poor, even though it is a physiologic route.
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Affiliation(s)
- Y Nakane
- 2nd Department of Surgery, Kansai Medical University, Osaka, Japan
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17
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Invited commentary. World J Surg 1995. [DOI: 10.1007/bf00295909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Affiliation(s)
- S M Berry
- Department of Surgery, University of Cincinnati Medical Center, Ohio
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19
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McAleese P, Calvert H, Ferguson WR, Laird J. Evaluation of "gastric" emptying time in the J pouch compared with a standard esophagojejunal anastomosis. World J Surg 1993; 17:595-9; discussion 599-600. [PMID: 8273380 DOI: 10.1007/bf01659117] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Gastric emptying times and symptoms were recorded in 18 patients after total gastrectomy and either a 15-cm J-pouch (n = 10) or a standard esophagojejunal anastomosis (n = 8). A solid test meal labeled with 99mTc was used to compare the emptying times. The postoperative symptoms and nutritional status were also assessed. The J-pouch resulted in a prolonged period of food retention in the upper jejunum (p < 0.02) compared to that with a standard esophagojejunal anastomosis. The patients with a J-pouch had fewer episodes of postprandial pain (p < 0.03) or vomiting (< 0.04). They also had fewer dietary restrictions (p < 0.04) and better nutritional status.
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Affiliation(s)
- P McAleese
- Department of Surgery, Ards Hospital, Newtownards, County Down, Northern Ireland
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20
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Abstract
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.
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Affiliation(s)
- F T Curran
- University Department of Surgery, Auckland Hospital, New Zealand
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21
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Heptner G, Domschke S, Domschke W. Exocrine pancreatic function after gastrectomy. Specificity of indirect tests. Gastroenterology 1989; 97:147-53. [PMID: 2656361 DOI: 10.1016/0016-5085(89)91428-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We compared intraindividually the specificity of indirect pancreatic function tests before and after total (n = 4; Roux-en-Y) or subtotal (n = 6; Billroth II) gastrectomy. Before gastrectomy only 1 patient showed a falsely pathological result with the pancreolauryl test (90% specificity), while the results of all the other tests were correctly normal (100% specificity using the usual cutoff limits). After gastrectomy the respective specificities were as follows: pancreolauryl test 10%, bentiromide test 70%, fecal chymotrypsin 70%, and plasma amino acid consumption test 100%. There was no obvious difference in the reduction of specificity between subtotal and total gastrectomy. The respective preoperative to postoperative changes in the median test data were as follows: plasma amino acid consumption test +21%, bentiromide test -12%, fecal chymotrypsin -51%, and pancreolauryl test -53%. It is concluded that after gastrectomy only the plasma amino acid consumption test is unaffected by postoperative anatomic alterations.
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Affiliation(s)
- G Heptner
- Department of Medicine, University of Erlangen-Nuremberg, Federal Republic of Germany
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22
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Abstract
Current conceptions of Ménétrier's disease only obliquely resemble those originally described. Bona-fide cases are so uncommon that, of 125 cases diagnosed as Ménétier's disease, hypertrophic gastritis, or protein-losing gastropathy treated at the Massachusetts General Hospital during the 26-year period of 1962-1987, only six cases merited an unequivocal anatomic diagnosis. Two other cases previously described proved on review to be nondiagnostic in one instance and Campylobacter pylori gastritis in the other. Because abnormalities in the secretion of gastric acid and in the loss of protein from the stomach may coexist, a representation of each case in semiquantitative terms can be described on triaxial coordinates. Three patients had a hypercoagulable state, one in association with gastric carcinoma. One other case of gastric carcinoma and one of esophageal carcinoma coexistant with Ménétrier's disease were identified. Administration of subcutaneous heparin during the perioperative period to patients with Ménétrier's disease is appropriate regardless of whether or not hypercoagulation or carcinoma is manifest. If treatment with anticholinergic drugs and inhibitors of gastric acid secretion fails, total gastrectomy is the best solution, because it stops protein loss, eliminates hyperchlorhydria, prevents development of gastric carcinoma, and permits anastomotic reconstruction between normal esophagus and normal small bowel.
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Affiliation(s)
- T M Sundt
- Surgical Services, Massachusetts General Hospital, Boston 02114
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