Near-total Gastrectomy Research Articles

Combined Laparoscopic Near-Total Gastrectomy and Colectomy

Synchronous gastrointestinal lesions of the abdomen are uncommon. Although laparoscopic gastric resection and colonic resection have been previously described, the combined laparoscopic resection of these 2 organs is unique. We report a case of a 72-year-old man with in situ gastric cancer and high-grade dysplasia of a colon polyp who underwent successful laparoscopic resection of both lesions. This report highlights the importance of preoperative planning and port placement in combined laparoscopic procedures.

Restorative caecogastroplasty reconstruction after pylorus-preserving near-total gastrectomy: A preliminary study

A wide range of inevitable adverse effects may emerge after total gastrectomy, mainly due to loss of reservoir organ and exclusion of the duodenal route. None of the available reconstructive methods has achieved a satisfactory functional result. A new method has been tried to overcome postgastrectomy problems. In this preliminary clinical study, a reconstruction technique involving interposition of the ileocaecal segment as a gastric substitute after pylorus-preserving near-total gastrectomy (restorative caecogastroplasty) was applied in six selected patients with proximal gastric carcinoma. Postoperative radiological and scintigraphic studies revealed adequate reservoir capacity, satisfactory neogastric emptying and a well functioning pyloric mechanism. During mean follow-up of 15 (range 3-36) months, dumping syndrome, reflux oesophagitis and weight loss were not observed. It is suggested that restorative caecogastroplasty combines the advantages of intact sphincter mechanisms and maintaining the duodenal route as well as sufficient reservoir volume. This method can be used safely as an alternative to other methods of reconstruction.

Restorative caecogastroplasty reconstruction after pylorus-preserving near-total gastrectomy: A preliminary study

Restorative caecogastroplasty reconstruction after pylorus-preserving near-total gastrectomy: A preliminary study

Gastrectomy for Complications of Bariatric Procedures.

BACKGROUND: Major complications of modern bariatric operations are infrequent but can be quite disabling to the patient and pose therapeutic challenges to the surgeon. We present our experience with five patients who underwent gastrectomy for complications following gastric reduction procedures. PATIENTS AND METHODS: Between 1991 and 1995, four women and one man, average age 46.8 years (34-66), underwent total gastrectomy and Roux-en-Y end-to-side esophagojejunostomy (4), or near-total gastrectomy with esophagogastrostomy (1). The decision to perform total gastrectomy was based on the poor quality of the remaining gastric pouch and the surgeon's judgement. Preoperative diagnoses included gastric outlet obstruction secondary to anastomotic ulcer or stricture, gastroesophageal reflux with esophagitis, chronic gastrocutaneous fistula, and iatrogenic linitis secondary to gastric wrap with mesh. Preoperatively, the patients complained of intolerable nausea, vomiting, abdominal pain, and dysphagia. RESULTS: in the five patients who underwent total or near-total gastrectomy, there was no operative mortality or morbidity; however, one patient (near-total gastrectomy) has required a second operation for pyloroplasty. Although one patient was lost to follow-up 6 months after surgery, the average follow-up for the remaining four patients is 2 years. These four patients were interviewed and all report complete satisfaction with their surgery and much improvement in their symptoms. Presently, they consume an average of three meals per day (range 2-6), with each meal measuring about 2 cups in size. All report the sensation of satiety after meals. All patients receive supplemental iron, B12, and multivitamins. From a nutritional standpoint, there has not been a significant change in the levels of albumin, total protein, hematocrit, weight and BMI since total gastrectomy. CONCLUSIONS: In our experience, total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy is an appropriate therapy with low morbidity and mortality in highly selected patients with complications resulting from gastric reduction procedures.

Motility Disorders after Roux-en-Y Gastrojejunostomy.

About 30% of patients who have a Roux-en-Y gastrojejunostomy after gastrectomy suffer from abdominal pain, nausea, vomiting of food and bloating made worse by eating. This syndrome, called the Roux stasis syndrome, is caused, in part, by a motility disorder of the Roux limb. Transection of the jejunum during the construction of the limb separates the limb from the natural small intestinal pacemaker located in the duodenum. Ectopic pacemakers then appear in the limb and trigger retrograde contractions in its proximal portion. These contractions slow transit through the limb and result in Roux stasis. Current nonsurgical treatment of the syndrome includes the use of prokinetic agents and intestinal pacing, neither of which has demonstrated long-term benefits. A near-total gastrectomy may speed upper gastrointestinal transit somewhat, but stasis in the Roux limb often persists. Our current approach alms at preventing the syndrome by the use of an 'uncut' Roux limb, an operation which preserves myoneural continuity between the duodenal pacemaker and the Roux limb and so prevents the appearance of ectopic pacemakers and stasis in the limb.

Postgastrectomy Syndromes

Anatomic and physiological changes introduced by gastric surgery result in postgastrectomy syndromes in approximately 20% of patients. Most of these disorders are caused by operation-induced abnormalities in the motor functions of the stomach, including disturbances in the gastric reservoir function, the mechanical-digestive function, and the transporting function. Division of the vagal innervation to the stomach and ablation or bypass of the pylorus are the most significant factors contributing to postgastrectomy syndromes. Either rapid or slow emptying may result, depending on the relative importance of lack of a compliant gastric reservoir, loss of an effective contractile force, and loss of controlling factors that slow or speed gastric emptying and result in duodenal-gastric reflux. Clearly defining which syndrome is present in a given patient is critical to developing a rational treatment plan. In syndromes with slow gastric emptying, bilious vomiting, or alkaline reflux gastritis, the use of endoscopy is essential to rule out mechanical causes of the syndrome. Contrast radiography and scintigraphic gastric emptying studies are useful to document rapid or delayed gastric emptying. Postgastrectomy syndromes often abate with time. Conservative measures, including medical, dietary, and behavioral therapy, should be given at least a 1-year trial. If these nonoperative measures fail, surgical therapy is recommended. The Roux-en-Y gastrojejunostomy is useful for patients with dumping, because it slows gastric emptying and the transit of chyme through the Roux limb. The same operation helps patients with alkaline reflux gastritis, because it diverts pancreaticobiliary secretions away from the gastric remnant. Near-total gastrectomy, which reduces the size of a flaccid gastric reservoir, can be used to treat delayed gastric emptying. This operation should be combined with the Roux procedure to prevent postoperative reflux gastritis and esophagitis. Newer techniques, such as gastrointestinal pacing and the uncut Roux operation, may improve the treatment of the postgastrectomy syndromes in the future.

Roux-Y gastrectomy for chronic gastric atony

The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients (11 men, 29 women; age 47 ± 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastroparesis. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades III and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.

Near-Total gastrectomy for gastric cancer

Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Total and near-total gastrectomy for gastric cancer in patients over 70 years of age

A total or near-total gastrectomy was performed in 52 patients over 70 years of age in our hospital from 1975 through 1982. The hospital mortality rate was 9.6 percent. The operation was palliative in nine patients. In these patients, the operation was performed because of an obstructing cancer. At last follow-up, 11 patients had survived more than 5 years and 6 patients were alive and free of disease more than 3 years after the operation. Total and near-total gastrectomies seem to be justified in elderly patients in good overall physical condition.

Near-total gastrectomy.

Total gastrectomy has more frequent and serious postoperative complications than subtotal gastrectomy. An esophago-gastric stoma with a side-to-side anastomosis permits a near-total gastrectomy to be undertaken with virtually the same results as a total gastrectomy. This procedure is used for early gastric cancers that have widely spreading, single or multiple lesions, or lesions near the esophago-gastric junction, and for the cure or palliative resection of selected patients with advanced gastric cancer.