J Korean Surg Soc.  2010 May;78(5):290-297. 10.4174/jkss.2010.78.5.290.

Near-Total Gastrectomy Preserving the Lower Esophageal Sphincter Followed by Jejunal Pouch Interposition as a Treatment for Upper Gastric Cancer

• Kim DJ
• Hur H
• Jeon HM
• Kim W

• KMID: 2211955
• DOI: http://doi.org/10.4174/jkss.2010.78.5.290

Abstract

PURPOSE
Conventional total gastrectomy with Roux-en-Y esophagojejunostomy has certain limitations such as insufficient food reservoir and malabsorption of nutrients. Therefore, we performed reconstruction of the jejunal pouch interposition (JPI) after near-total gastrectomy preserving the lower esophageal sphincter (LES). We compared the technical feasibility, safety, and surgical outcome of this operation with conventional total gastrectomy accompanying with Roux-en-Y esophagojejunostomy.
METHODS
From April 2003 to October 2005, 15 LES-preserving, near-total gastrectomies with JPI (LES-JPI group) were performed. The clinical features and surgical outcomes were retrospectively compared with 17 cases of conventional R-Y esophagojejunostomy. Statistical analysis was performed using Fisher's exact test for categorical data and an unpaired t-test for continuous data.
RESULTS
Clinicopathological features of the LES-JPI and R-Y groups did not show differences excepting patient age (50.8+/-5.8 years vs. 62.8+/-12.4, respectively; P=0.002) and the depth of tumor invasion (T1-T2; 11~4 vs. 5~12; P=0.032). The operative outcomes for the two groups significantly differed in terms of operation time (676 vs. 484 min; P=0.008) and blood loss (424 vs. 336 ml; P=0.006). Postoperative gastrofiberscopic examination of all LES-JPI patients showed no esophageal reflux or strictures and intact LES. In addition, the LES-JPI group did not experience swallowing difficulty or stricture.
CONCLUSION
LES-preserving total gastrectomy with JPI is a feasible and safe procedure for patients with upper gastric cancer.

Keyword

Gastric cancer; Lower esophageal sphincter; Jejunal pouch interposition

MeSH Terms

Constriction, Pathologic
Deglutition
Esophageal Sphincter, Lower
Gastrectomy
Gastroesophageal Reflux
Humans
Retrospective Studies
Stomach Neoplasms

Figure

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  Fig. 1 Proximal resection. Auto-purse string device is applied for proximal resection at a distance of 1.5 to 2.5 cm from the lower esophageal sphincter.

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  Fig. 2 Jejunal pouch reconstruction. Jejunal pouch is reconstructed in a side-to-side manner, using a 100-mm GIA stapler. (A) Application of a GIA device. (B) Completion of a jejunal pouch.

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  Fig. 3 Anastomosis. Jejunal pouch is anastomosed between proximal cardia and duodeneum. (A) An illustration. (B) An upper gastrointestinal contrast test.

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  Fig. 4 Comparision of perioperative changes in nutritional markers. The groups showed no statistically significant differences in terms of (A) total protein, albumin, or (B) prognostic nutritional index. P-values refer to the differences in the change of the nutritional markers from their preoperative level between the two groups.

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  Fig. 5 A comparison of the proportion of body weight loss relative to preoperative body weight. Postoperative weight loss in the LES-JPI group (8.70~9.12%) was lower than that in the R-Y group (10.57~14.13%), the difference was not statistically significant. P-values refer to the differences in the change of the weight from their preoperative level between the two groups.

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