Billroth-II Reconstruction Research Articles

Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer

To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a self-expandable metal stent (SEMS) for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer. The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary's Hospital, were reviewed retrospectively. Twenty patients (15 male, mean age 63 years) were included. The operations were a total gastrectomy with esophagojejunostomy (n = 12), subtotal gastrectomy with Billroth-I reconstruction (n = 2) and subtotal gastrectomy with Billroth-II reconstruction (n = 8). The technical and clinical success rates were 100% and 70%, respectively. A small bowel or colon stricture was the reason for a lack of improvement in symptoms in 4 patients. Two of these patients showed improvement in symptoms after another stent was placed. Stent reobstruction caused by tumor ingrowth or overgrowth occurred in 3 patients (15%) within 1 mo after stenting. Stent migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-II reconstruction. Two cases of partial stent migration were easily treated with a second stent or stent repositioning. The median stent patency was 56 d (range, 5-439 d). The median survival was 83 d (range, 12-439 d). Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer. A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.

ACUTE PANCREATITIS CAUSED BY AFFERENT LOOP OBSTRUCTION AFTER GASTRECTOMY WITH BILLROTH-II

Afferent loop obstruction is a very rare cause of acute pancreatitis. We report a care of severe acute pancreatitis caused by afferent loop obstruction after partial gastrectomy. A 82-years-old man was admitted to our hospital because of nausea and upper abdominal pain. He underwent partial gastrectomy with Billroth-II reconstruction due to gastric cancer for 25 years ago. Abdominal computer tomography scan showed markedly dilated duodenum, located behind the superior mesenteric artery. Therefore we diagnosed severe acute pancreatitis due to afferent loop obstruction. After the percutaneus drainage of dilated duodenum, acute pancreatitis was significantly improved. We conclude that decompression of the dilated duodenum will be a useful treatment in the patient with acute pancreatitis due to afferent loop obstruction.

Roux-en-Y Reconstruction after Distal Gastrectomy to Reduce Enterogastric Reflux and Helicobacter pylori Infection

Enterogastric reflux (EGR) is regarded as an unavoidable consequence of distal gastrectomy. We evaluated the efficacy of Roux-en-Y (RY) gastrojejunostomy and Braun enteroenterostomy (BEE) for preventing EGR. Between January 2002 and January 2005, 60 patients who underwent distal gastrectomy for gastric cancer or peptic ulcers were divided into RY, Billroth II reconstruction (BII) without or with BEE (BII+B) according to reconstructive method. After 12 months, EGR and mucosal alterations of the remnant stomach were evaluated using biliary scintigraphy, endoscopy, and histology. Scintigraphy showed fasting and postprandial EGR into the remnant stomach occurred in 5.3% and 21.1% of the RY group, 62.1% and 93.1% of the BII group, and 50.0% and 91.7% of the BII+B group, respectively. Endoscopy showed bile reflux occurred in 15.8% of the RY group, 75.9% of the BII group, and 83.3% of the BII+B group. In addition, the prevalence of Helicobacter pylori (HP) infection in the RY group was less than in the other groups (P < 0.02). Therefore, RY after distal gastrectomy was effective in reducing EGR and HP infection. BEE was ineffective in diverting bile flow away from the gastric remnant.

GI Cancer High Prevalence of Epstein-Barr Virus in Gastric Remnant Carcinoma after Billroth-II Reconstruction

Background : Epstein-Barr virus (EBV) has been detected in about 10% of gastric carcinoma cases worldwide, and a high prevalence of EBV involvement in gastric remnant carcinoma has been reported recently. Details of the background remnant stomach of EBV-positive lesions, however, have not been well clarified. Methods : We screened 17 consecutive gastric remnant carcinoma lesions resected surgically. To detect EBV, we used in situ hybridization (ISH) for EBV-encoded small RNA1 (EBER-1) and we compared the clinicopathologic feature between EBV-positive and-negative gastric remnant carcinoma cases. Results : EBV was detected in 41.8% (7 of 17) of the lesions by EBER-1 ISH. All 7 EBVpositive lesions developed in the anastomotic site had undergone Billroth-II reconstruction excess 20 years previously (mean 26.4 years). Histologically, all EBV-positive lesions were poorly differentiated adenocarcinomas with intense lymphocyte infiltration. In the adjacent mucosa of carcinomas, moderate or marked intestinal metaplasia was found in 85.7% (6 of 7) of EBV-positive lesions and in 40% (4 of 10) of EBV-negative lesions. Conclusions : EBV infection is strongly associated with gastric remnant carcinoma. Atrophic change of remnant gastritis in Billroth-II anastomoses is considered to be the carcinogenic background for EBV-positive gastric remnant carcinoma.

Quality of Life and Nutritional Outcomes of Billroth I and Billroth II Reconstruction

Purpose: We compared the quality of life (QOL) and nutritional outcomes following both Billroth I (BI) and Billroth II (BII) reconstructions after a subtotal gastrectomy in order to identify which reconstruction would produce a better QOL and nutritional outcomes and to provide better follow-up management. Materials and Methods: We studied 273 patients without evidence of recurrent disease following a curative distal subtotal gastrectomy for gastric cancer. Among them, 135 underwent a BI reconstruction and 138 a BII reconstruction. The nutritional status was assessed by using levels of hemoglobin, serum albumin, iron, and vitamin B12 and by calculating the relative body weight, the body mass index, and the percentage of body fat. The QOL was measured by using the Troidl score and by treatment-specific symptoms based on the criteria, somewhat modified by the authors, of Korenaga and others. Results: There was no significant difference in QOL between the BI and the BII groups. More than half of the patients revealed anemia, regardless of the type of reconstruction. The serum vitamin level of the BII group was lower than that of the BI group. The BII group showed a tendency toward lower hemoglobin levels and serum iron concentrations than the BI group did. Conclusions: The quality of life was not impaired in most patients after either a BI or a BII reconstruction. However, both resulted in iron deficiency anemia, although the incidence was higher after a BII reconstruction. The patient's serum iron and vitamin B12 should be measured periodically and these must be administered if the measurements reveal a below normal range.

GI Cancer High Prevalence of Epstein-Barr Virus in Gastric Remnant Carcinoma after Billroth-II Reconstruction

Background : Epstein-Barr virus (EBV) has been detected in about 10% of gastric carcinoma cases worldwide, and a high prevalence of EBV involvement in gastric remnant carcinoma has been reported recently. Details of the background remnant stomach of EBV-positive lesions, however, have not been well clarified. Methods : We screened 17 consecutive gastric remnant carcinoma lesions resected surgically. To detect EBV, we used in situ hybridization (ISH) for EBV-encoded small RNA1 (EBER-1) and we compared the clinicopathologic feature between EBV-positive and-negative gastric remnant carcinoma cases. Results : EBV was detected in 41.8% (7 of 17) of the lesions by EBER-1 ISH. All 7 EBVpositive lesions developed in the anastomotic site had undergone Billroth-II reconstruction excess 20 years previously (mean 26.4 years). Histologically, all EBV-positive lesions were poorly differentiated adenocarcinomas with intense lymphocyte infiltration. In the adjacent mucosa of carcinomas, moderate or marked intestinal metaplasia was found in 85.7% (6 of 7) of EBV-positive lesions and in 40% (4 of 10) of EBV-negative lesions. Conclusions : EBV infection is strongly associated with gastric remnant carcinoma. Atrophic change of remnant gastritis in Billroth-II anastomoses is considered to be the carcinogenic background for EBV-positive gastric remnant carcinoma.

MESENTERIC FIBROMATOSIS AFTER GASTRECTOMY FOR A GASTRIC CANCER -REPORT OF A CASE-

Mesenteric fibromatosis is a rare tumor. It has been reported that the disease is associated with Gardner's Syndrome, as well as with abdominal traumas, such as surgery, injury, and pregnancy. This report discribes a case of mesenteric fibromatosis which developed 29 months after gastrectomy for a gastric cancer. A 56-year-old man underwent distal gastrectomy with a Billroth-II reconstruction for an early gastric cancer of the pylorus (t1, n1). Twenty-nine months later, an easily movable tumor, about 4 cm in diameter, was palpated in the left upper quadrant of the abdomen. It was believed to be a local recurrence of the gastric cancer. Laparotomy was performed and a hard elastic tumor, measuring 4 cm in diameter was found in the mesentery of the jejunum 60 cm distal to the Billroth-II anastomosis. The lymph nodes in the root of the mesentery swelled and measured about 1 cm in diameter. The tumor was removed along with about 1 m of the jejunm. Histological examination revealed that the tumor consisted of bundles of spimdle cells which had invaded the submucosal layer of the jejunm from the mesentery. The tumor cells stained positive for vimentin and negative for S-100 protein, using the indirect immunostaining technique. Based on these findings, the leasion was diagnosed as mesenteric fibromatosis. The patient is doing well without recurrence for 26 months after the following resection.

The effect of Roux-en-Y diversion on gastric and roux-limb emptying in a rodent model

The "Roux stasis syndrome" is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy (RG). Whether symptoms result from delayed gastric emptying, altered Roux-limb transit, or both has never been settled, partly because of the difficulty of measuring Roux-limb transit. The aim of this study was to develop a model to simultaneously quantitate Roux-limb transit and gastric emptying. Rats underwent vagotomy and antrectomy with RG or Billroth II reconstruction (B-II). Gastrointestinal transit of a solid meal (Technetium-99m sulfur colloid-labelled egg white) was assessed 0.5, 1, and 1.5 hours postprandial (pp). Transit of a liquid marker (Na51-CrO4 injected through an efferent-limb catheter) was measured at 25 minutes pp. Solid gastric emptying was slower in RG than in B-II rats at 60 and 90 minutes pp. More of the solid meal and of the liquid marker was retained in the Roux limb than the efferent limb of the B-II at all time points (P < 0.05). In a rodent model, Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying and slowed efferent-limb transit of solids and liquids.

Operationsfolgen nach Whipple&amp;rsquo;scher Resektion

Patients with a partial pancreatoduodenectomy mainly suffer over the long-term course from the sequelae of endocrine and exocrine pancreas insufficiency. Insulin-dependent diabetes is to be expected in about 10% of the cancer patients. 25% of patients who undergo resection for chronic pancreatitis are already diabetic before surgery. Postoperatively, this percentage tends to increase due to the progressive scarred transformation of the residual gland, rather than due to the intervention itself. Steatorrhea as an expression of exocrine pancreas insufficiency is observed in 50% of all patients after intervention. Oral enzyme substitution can demonstrably improve this situation. Dumping symptoms are observed comparatively rarely (less than 10%) after Whipple’s resection. In contrast, gastrojejunal anastomotic ulcers represent a high potential for complications in up to 50% of the patients. Additional vagotomy does not reduce the rate of ulcers. Some observations have shown that the rate of ulcers in gastrojejunal Roux-en-Y anastomosis (19%) is higher than after Billroth-II reconstruction (0%). Partial pancreatoduodenectomy with preservation of the pylorus and proximal duodenal bulb is characterized by a pronounced impairment of stomach evacuation in the early post-