Jejunal Interposition Research Articles

Selection of the Surgical Approach for Reoperation of Adult Choledochal Cysts

Background/PurposeOur purpose was to evaluate the reasons for reoperations and outcomes in patients with choledochal cysts (CCs). MethodsThe records of patients with CCs who underwent reoperations from 1995 to 2012 were retrospectively reviewed. ResultsOf 165 patients with a mean age of 42.54±14.05 years, 62 had Todani type I (37.6 %), 84 type IV-A (50.9 %), and 19 had unknown type CCs (11.5 %). Previous surgery was internal or external drainage alone in 66.1 % of patients with type I and 23.8 % of patients with type IV-A CCs. Partial cyst excision and Roux-en-Y cyst-jejunostomy or cyst excision and choledochoplasty by jejunal interposition were performed in 16.1 and 11.3 % of patients with type I and IV-A CCs, respectively. Reoperations at our hospital were maximal cyst excision and Roux-en-Y hepaticojejunostomy. Radical cyst excision was achieved in 93.5 % of patients with type I and 44.0 % of patients with type IV-A CCs. With an average follow-up of 48.23±12.30 months, recurrent cholangitis and biliary-enteric anastomotic stenosis occurred in 18 (13.2 %) and 9 patients (6.6 %), respectively. Long-term biliary function was excellent or good in 83.8 % of patients. ConclusionsRadical cyst excision and Roux-en-Y hepaticojejunostomy provide good outcomes in patients with CCs.

A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy.

An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem. We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005. Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group. The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.

Strategies of surgery treatment for cervical esophageal cancer

To explore the methods and means of surgical treatment for cervical esophageal cancer in order to get the best efficacy. Retrospective investigation and analysis were carried out in 137 patients with cervical esophageal cancer undergoing operation in our hospital from January 2005 to December 2013. According to lesion locations, these cases were divided into two groups: larynx preservation group(Group A) and laryngectomy group(Group B). Surgery options of Group A included inversion esophagectomy without thoracotomy, three-incision esophagectomy, end to end anastomosis of cervical esophagus after local resection. Group B included gastric-pharyngeal anastomosis, pharyn-esophagus plasty, colon replacement of the esophagus or jejunal interposition. All the patients received postoperative adjuvant therapy. There were no perioperative deaths. The main postoperative complications included anastomotic fistula in 20 cases(14.6%), postoperative massive bleeding after inversion esophagectomy in 3 cases, chylothorax in 1 case, anastomotic stenosis in 9 cases, severe gastroesophageal reflux in 6 cases and serious aspiration pneumonia in 2 cases. All these patients had complete resolution of disease with good postoperative quality of life. The 1-year, 3-year and 5-year survival were 73.7%, 48.4% and 26.8% respectively. The most important causes of postoperative death included local recurrence, cervical or mediastinal lymph node metastases, cachexia and multiple organic metastasis. It is critical to select reasonable methods of operations to reduce postoperative complications and to receive proper adjuvant therapy.

A two-center comparative study of gastric pull-up and jejunal interposition for long gap esophageal atresia

PurposeWhen restoration of the anatomical continuity in case of long gap esophageal atresia (LGEA) is not feasible, esophageal replacement surgery becomes mandatory. The aim of this paper is to critically compare the experience of two tertiary referral centers in The Netherlands performing either gastric pull-up (GPU) or jejunal interposition (JI). MethodsRetrospective chart review of all the patients with LGEA who underwent GPU in the University Medical Center Groningen and JI in the University Medical Center Utrecht. Main endpoints were short term morbidity, mortality and long term functional outcome (digestive functioning and growth). Descriptive analyses conducted using Mann–Whitney U test for continuous variables and Fisher's exact test for categorical variables. ResultsNine children underwent GPU and 15 JI. Median age (years) at last follow up was fourteen (GPU) and eight (JI). One patient died, 10years after JI. No grafts were lost. Perioperative anastomotic complications were reported more often after JI (73% vs. 22%, p=0.03). However reintervention rate was the same in both groups (33%). Among long term outcomes, functional obstruction was not registered after GPU, while it was recorded in 46% after JI (p=0.02). No other significant differences were found apart from some tendencies concerning full oral nutrition and gastroesophageal reflux (GPU>JI). ConclusionComparative data from this study reveal no mortality but significant morbidity in both groups. No graft was lost. Although not statistically different as a result of small patient numbers, clinically important differences regarding gastrointestinal system were noted. Growth should be monitored closely in both groups.

Free jejunum reconstruction and laryngeal preservation for squamous cell carcinoma in the pharyngoesophageal junction

Try to use free jejunum flaps reconstruction and laryngeal preservation for squamous cell carcinoma (SCC) in the pharyngoesophageal junction. Thirteen patients who underwent resections of SCC in the pharyngoesophageal junction with free jejunal interposition from August 2007 to December 2012 were reviewed. Of them, 8 had T3 lesions, 4 had T4 lesions, and one had radiation failure with rT2 lesion. Ten patients were treated with postoperative radiotherapy with a average dosage of 56 Gy. The 3 year over all survival rate was 47.9% and disease-specific survival rate was 34.2%. The surgical complications occurred in 9 patients (9/13), including one death and one flap failure. Five patients (5/13) had permanent tracheal canulation, 10 patients (10/13) resumed oral feeding and all patients achieved reasonable speech. Free jejunum interposition can be used to reconstruct surgical defect of SCC in the pharyngoesophageal junction, thus preserving the larynx and ensuring a better quality of life for the patients.

Photodynamic therapy for local recurrence of esophageal cancer in the esophagus after resection and free jejunal loop interposition for pharyngeal cancer

a Department of Gastroenterology, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan b Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan c Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Address: 3-39-22 Showamachi, Maebashi, Gunma 371-8511, Japan Available online 2 June 2014

Jejunal graft conduits after esophagectomy.

The jejunum is uniquely suitable for esophageal reconstruction because it is relatively abundant, does not require a formal preparation, is typically free of disease, has similar luminal size compared to the esophagus, has intrinsic peristalsis, and may not undergo senescent lengthening to the extent that colon does. To obtain data to determine the outcomes of jejunal interposition for esophageal replacement, electronic databases were searched, including MEDLINE (Ovid SP), Scopus, EMBASE (Ovid SP), Science Direct's full-text database, and the Cochrane Library from January 1990 to September 2013. Two-hundred and forty-six abstracts were reviewed and an article search was performed on selected abstracts. Additional references from article bibliographies were included as appropriate. A thorough search of the literature demonstrates the widespread use of jejunum, either as a free, pedicled, or free- and pedicled-graft with acceptable results. Any region of the esophagus can be replaced by jejunum, whether it is distal esophagus as a Merendino procedure for a vagal-sparing esophagectomy and segmental jejunal reconstruction connected to stomach, mid-thoracic esophagus as a pedicled jejunal interposition or free flap, cervical esophagus as a free segmental interposition, or the entire length as a long-segment super-charged pedicled jejunal interposition. When used, the jejunum is either pedicled, augmented ("super-charged"), a free segment (requiring microvascular anastomosis of artery and vein), or a combination of the above.

Novel laparoscopic procedure for treating proximal early gastric cancer: laparoscopy-assisted pylorus-preserving nearly total gastrectomy.

Pylorus-preserving nearly total gastrectomy (PPNTG) is a function-preserving gastrectomy for treating proximal early gastric cancer that prevents rapid gastric emptying and reflux. In this report, we present a surgical technique for performing laparoscopy-assisted PPNTG (LAPPNTG). The resection of the stomach was similar to that during conventional total gastrectomy, with the key difference being that the pyloric cuff was preserved to a length of 3-4cm. Compared with standard total gastrectomy, the lymph node dissection along the right gastric vessels and the infrapyloric vessels were omitted. Reconstruction was performed with a jejunal interposition that was 30cm in length, with preservation of the marginal vessels in a retrocolic fashion. Thirteen patients with cT1 cN0 proximal gastric cancer underwent LAPPNTG at our institution. The median length of the operation and estimated blood loss were 329min and 138ml, respectively. All resected specimens had tumor-free margins, and the median number of removed lymph nodes was 40. There were no serious postoperative complications and no patients underwent conversion to laparotomy. Performing LAPPNTG with a jejunal interposition is feasible and might be an appropriate treatment for proximal early gastric cancer.

Reconstruction of digestive tract after distal gastrectomy

There are various types of digestive tract reconstruction techniques after distal gastrectomy. Among them, Billroth I and II are still the predominant option in China at present. In recent years, Roux-en-Y configuration, jejunal interposition, J-pouch interposition (JPI), double-tract reconstruction, pylorus-preserving method, and laparoscopic reconstruction and anastomosis techniques have gained more attention in recent years. Although there is no universal and explicit guideline, the current consensus is that the reconstruction style should be adopted by the principles of digestive tract reconstruction, based on patient's condition, socioeconomic status and surgeon's experience.

Two types of digestive tract reconstruction after proximal gastrectomy for early gastroesophageal junction adenocarcinoma: a randomized controlled study

To investigate the better method of digestive tract reconstruction in proximal gastrectomy for early gastroesophageal junction adenocarcinoma. A total of 153 cases of early gastroesophageal junction adenocarcinoma who were planned to receive radical proximal gastrectomy from January 2003 to December 2011 were prospectively enrolled and randomly divided into two groups by table of random number according to methods of digestive tract reconstruction, including 3S anastomosis group (80 cases, 3S jejunal interposition) and traditional anastomosis group (73 cases, esophageal remnant gastric posterior wall anastomosis). Postoperative complications, operative time, mortality, nutritional parameters and postoperative quality of life were compared between these two groups. There were no significant differences between two groups in postoperative complications, operative time and mortality (all P>0.05). 3S anastomosis group was better in nutritional parameters than traditional group six months after operation (P<0.05). As compared to traditional group, incidence of reflux esophagitis decreased [20.0%(16/80) vs. 46.6%(34/73), P<0.01] and gastric emptying time prolonged obviously [(160.8±8.1) min vs. (61.1±10.8) min, P<0.01] in 3S anastomosis group 18 months after operation. Postoperative QLQ-C30 rating scale revealed quality of life was significantly higher in 3S anastomosis group as compared to traditional group. Jejunal interposition is a better method of digestive tract reconstruction in proximal gastrectomy for early gastroesophageal junction carcinoma.

Reconstruction after proximal gastrectomy for early gastric cancer in the upper third of the stomach: An analysis of our 13-year experience

Fundoplication during esophagogastrostomy (EG) after proximal gastrectomy (PG) is a useful procedure to prevent reflux esophagitis, but it is unclear how much of the remnant stomach should be wrapped around the esophagus. We analyzed data from 101 patients who underwent PG for upper third early gastric cancer between 1999 and 2011. In all, 64 patients underwent EG, 25 underwent jejunal interposition (JI), and 12 underwent jejunal pouch interposition (JPI). We compared intraoperative details and postoperative outcomes, and investigated the relationships between the degree of the fundoplication during EG and endoscopic findings. The length of the operation was significantly shorter in the EG group than in the other 2 groups (P < .05), and the intraoperative blood loss was significantly less in the EG group (P < .05). The JI and the JPI groups had significantly greater rates of early complications than did the EG group (P = .01). Reflux esophagitis was present in 22% of patients in the EG group, 8% in the JPI group, and none in the JI group. In the EG group, reflux esophagitis was significantly less common in patients with a >180° wrap of the remnant stomach around the esophagus than in patients with a smaller wrap (P = .0008). The rate of body weight loss was significantly less in the EG group compared with the other 2 groups (P < .05). Considering the low invasiveness of the procedure and postoperative outcomes, we consider that EG with a >180° wrap as the optimal reconstructive procedure.

Laparoscopic functional single loop type jejunum interposition

Laparoscopic functional single loop type jejunum interposition for the radical resection of cancers at the esophagogastric junction or the fundus of the stomach is safe,feasible and can prevent reflux esophagitis and dumping syndrome.From January 2011 to January 2013,12 gastric cancer patients received laparoscopic functional single loop type jejunum interposition at the General Hospital of Lanzhou Military Region.No patient died perioperatively.There was 1 patient complicated with anastomotic bleeding and was cured by conservative treatment.All the patients were followed up for 6 months,no anastomotic fistula,stricture,bile or food reflux,malnutrition or dumping syndrome was detected,and satisfactory postoperative results was achieved. Key words: Adenocarcinoma of the esophagogastric junction; Laparoscopy; Single channel; Jejunum interposition

Long-term outcome and quality of life after supercharged jejunal interposition for oesophageal replacement

BackgroundThe consequences of major conduit necrosis following oesophagectomy are devastating. Jejunal interposition with vascular supercharging is an alternative reconstructive method if colon is unavailable. Aims of this study were to review the long-term outcome and quality of life of patients undergoing this surgery in our tertiary unit. MethodsPatients undergoing oesophageal reconstruction with supercharged jejunum were identified and retrospective review of hospital notes performed. Each patient was then interviewed for follow up data and quality of life assessment using the EORTC QLQ-C30 questionnaire. ResultsSix patients (5 men) (median age 59 years (range 34–72) underwent supercharged pedicled jejunal (SPJ) interposition from May 2005–August 2010. Indications for surgery were loss of both gastric and colonic conduits following surgery for oesophageal cancer (n = 4), loss of gastric conduit and previous colectomy (n = 1) and lastly, gastric and colonic infarction in a strangulated paraoesophageal hernia (n = 1). Median time to reconstruction was 12 months [6–15 range]. There were no in-hospital deaths. Median postoperative stay was 46 days [13–118]. Three patients required surgical re-intervention for leak, sepsis and reflux, respectively. Median follow up was 6.5 years [range 7–102 months]. One patient died seven months following surgery due to respiratory complications. On follow up, 5 patients have an enteral diet without supplemental nutrition, maintaining weight and good quality of life scores. ConclusionsSupercharged jejunal interposition is a suitable alternative conduit for delayed oesophageal replacement in patients with otherwise limited reconstructive options. Good functional outcomes can be achieved despite formidable technical challenges in this group.

Total gastrectomy with isoperistaltic jejunal interposition flap for symptomatic management of gastric polyposis from familial adenomatous polyposis.

Patients with familial adenomatous polyposis (FAP) oftentimes have extracolonic polyps. The patient discussed in this case report had innumerable gastric polyps which were significantly affecting his ability to tolerate oral intake and his overall nutrition. Medical management was not sufficiently controlling his symptoms; therefore we proceeded with surgical intervention. We discuss the use of a total gastrectomy with an Isoperistaltic jejunal interposition flap for the symptomatic management of gastric polyposis. We describe the technique used and benefits to this specific procedure when it comes to long term outcome, complications, and monitoring.

Technical Improvement of Total Pharyngo-Laryngo-Esophagectomy for Esophageal Cancer and Head and Neck Cancer

Total pharyngo-laryngo-esophagectomy (PLE) is highly invasive, and the subsequent reconstruction is difficult. The purpose of this study was to clarify the techniques that can decrease the surgical stress and allow for safe reconstruction after this operation. The surgical method and clinical outcomes of total PLE were reviewed in 12 patients with either cervicothoracic esophageal cancer or double cancer of the esophagus and pharynx. Microscopic venous anastomosis was principally performed, and arterial anastomosis was added, if needed. A narrow gastric tube was used in ten patients, including two patients who underwent free jejunal interposition, while the colon was used as the main reconstructed organ in two other patients. Staged operations were performed in three high-risk patients. All six patients treated after 2010 were able to undergo thoracoscopic and/or laparoscopic surgery. No critical postoperative complications developed, although minor anastomotic leakage developed in two patients who were successfully treated conservatively. When performing PLE, it is important to decrease the surgical stress and ensure a reliable reconstruction by adopting techniques that are appropriate for each case, such as thoracoscopic and laparoscopic surgery, staged operations, microvascular anastomosis, and muscular flaps.

Functional outcomes by reconstruction technique following laparoscopic proximal gastrectomy for gastric cancer: double tract versus jejunal interposition

BackgroundFor early gastric cancer located in the upper third of the stomach, we have adopted laparoscopic 1/2-proximal gastrectomy (PG) with two types of reconstruction: double tract reconstruction (L-DT) and jejunal interposition reconstruction with crimping of the jejunum on the anal side of the jejunogastrostomy with a knifeless linear stapler (L-JIP).MethodsFunctional outcomes were prospectively compared between these two types of reconstruction following laparoscopic PG. Resection and reconstruction were performed using L-DT (n = 10) and L-JIP (n = 10) alternately. Quality of life was evaluated through a questionnaire and endoscopic examination of the ten patients in each group, and functional evaluations were carried out in five patients of each group.ResultsThe postoperative/preoperative body weight ratio was significantly higher in the L-JIP group than in the L-DT group. While the incidence of reflux esophagitis was 10% in both groups, the endoscope could reach the remnant stomach in all patients. In the L-DT group, the plasma acetaminophen concentration at 15 minutes and the insulin level at 30 minutes were markedly increased after oral administration, while the increases in the blood sugar level at 30 and 60 minutes were more gradual than in the L-JIP group.ConclusionsWhile L-JIP may be thought of as the ideal method for function-preserving gastrectomy, L-DT may be suitable for gastric cancer patients with impaired glucose tolerance. These results raise the possibility of individualized selection of reconstruction for gastric cancer patients with various kinds of preoperative complications.

Surgical Resection of Hypopharynx and Cervical Esophageal Cancer with a History of Esophagectomy for Thoracic Esophageal Cancer

Cancer of the hypopharynx and cervical esophagus (PhCe cancer) frequently develops synchronously or metachronously with esophageal cancer. The surgical approach is usually difficult, especially in metachronous PhCe cancer after esophagectomy. The purpose of this study was to clarify the treatment outcomes of patients with metachronous PhCe cancer with a history of esophagectomy. The subjects evaluated in this study were 14 patients with metachronous PhCe cancer who underwent pharyngo-laryngo-esophagectomy after subtotal esophagectomy and gastric tube pull-up for primary esophageal cancer. Definitive chemoradiotherapy (CRT; radiation dose >50 Gy) was performed for primary laryngeal (n = 1), pharyngeal (n = 2), esophageal (n = 1), and recurrent esophageal cancer (n = 2). For seven patients with metachronous PhCe cancer, induction CRT (radiation dose <40 Gy) was performed. In all 14 patients, pharyngo-laryngo-esophagectomy was followed by free jejunal graft interposition with reconstruction of the jejunal vessels. Although postoperative complications developed in four patients, no perioperative death or necrosis of the reconstructed free jejunum occurred. The 2- and 5-year overall survival rates were 84 and 50 %, respectively. Pharyngo-laryngo-esophagectomy with free jejunal transfer is considered to be safe for metachronous PhCe cancer, even in patients with a history of CRT and esophagectomy.

Kampo medicine for palliative care in Japan

Kampo medicines are currently manufactured under strict quality controls. The Ministry of Health, Labour and Welfare of Japan has approved 148 Kampo formulas. There is increasing evidence for the efficacy of Kampo medicines, and some are used clinically for palliative care in Japan. The specific aim of this review is to evaluate the clinical use of Kampo medicines in palliative care in the treatment of cancer. The conclusions are as follows: Juzentaihoto inhibits the progression of liver tumors in a dose-dependent manner and contributes to long-term survival. Hochuekkito has clinical effects on cachexia for genitourinary cancer and improves the QOL and immunological status of weak patients, such as postoperative patients. Daikenchuto increases intestinal motility and decreases the postoperative symptoms of patients with total gastrectomy with jejunal pouch interposition, suppresses postoperative inflammation following surgery for colorectal cancer, and controls radiation-induced enteritis. Rikkunshito contributes to the amelioration of anorectic conditions in cancer cachexia-anorexia syndrome. Goshajinkigan and Shakuyakukanzoto reduce the neurotoxicity of patients with colorectal cancer who undergo oxaliplatin and FOLFOX (5-fluorouracil/folinic acid plus oxaliplatin) therapy. Hangeshashinto has the effect of preventing and alleviating diarrhea induced by CPT-11(irinotecan) and combination therapy with S-1/CPT-11. O’rengedokuto significantly improves mucositis caused by anticancer agents.

Comparison of Perioperative and Long‐term Outcomes of Total and Proximal Gastrectomy for Early Gastric Cancer: A Multi‐institutional Retrospective Study

Various surgical procedures are used to treat early gastric cancers in the upper third of the stomach (U-EGCs). However, there is no general agreement regarding the optimal surgical procedure. The medical records of 203 patients with U-EGC were collected from 13 institutions. Surgical procedures were classified as Roux-en-Y esophagojejunostomy after total gastrectomy (TG-RY), esophagogastrostomy after proximal gastrectomy (PG-EG), or jejunal interposition after PG (PG-JI). Patient clinical characteristics and perioperative and long-term outcomes were compared among these three groups. TG-RY, PG-EG, and PG-JI were performed in 122, 49, and 32 patients, respectively. Tumors were larger in TG-RY patients than in PG-EG and PG-JI patients, and undifferentiated-type gastric adenocarcinoma tended to be more frequent in TG-RY than in PG-EG. The operative time was shorter for PG-EG than for PG-JI and TG-RY. Hospital stay and early postoperative complications were not different for the three procedures. With respect to gastrectomy-associated symptoms, a "stuck feeling" and heartburn tended to be more frequent in PG-EG patients, while dumping syndrome and diarrhea were more frequent in TG-RY patients. Post-surgical weight loss was not different among the three groups, however, serum albumin and hemoglobin levels tended to be lower in TG-RY patients. Three surgical procedures for U-EGC did not result in differences in weight loss, but PG-EG and PG-JI were better than TG-RY according to some nutritional markers. In U-EGC, where patients are expected to have long survival times, PG-EG and PG-JI should be used rather than TG-RY.

Feasibility and functional efficacy of distal gastrectomy with jejunal interposition for gastric cancer: A case series

IntroductionDistal gastrectomy with jejunal interposition (DGJI) has been used in our institution for selected patients with gastric cancer as a function-preserving gastrectomy. The aim of this retrospective study was to clarify the feasibility and functional efficacy of DGJI. MethodsA retrospective analysis was performed in 61 patients who underwent DGJI between 2002 and 2011. ResultsMean operation time was 393.8 min and blood loss was 463.3 ml. Postoperative early major complications developed in 2 (3.3%) patients. The most common complication was gastric stasis, occurring in 7 (11.5%) patients. All patients with complications recovered with conservative treatment, and no operative mortality occurred. Endoscopy 1 year after operation revealed reflux gastritis in 1 patient. Reflux esophagitis was not found in any patient. However, anastomotic ulcer was found in 12 (22.2%) patients over the 1-year period after operation. No patient reported symptoms of early and late dumping syndrome, and 1 (1.9%) patient self-reported diarrhea. ConclusionsDGJI was a feasible and safe procedure with several advantages in terms of less incidence of reflux gastritis and esophagitis, dumping syndrome and diarrhea. However, this procedure is complicated and time-consuming, and it is necessary to be aware of the potential occurrence of an anastomotic ulcer at the site of the gastrojejunostomy after DGJI.