Open Access, Peer-reviewed
pISSN 2288-6575
eISSN 2288-6796
    J Korean Surg Soc. 2010 May;78(5):290-297. Korean.
    Published online May 11, 2010.
    https://doi.org/10.4174/jkss.2010.78.5.290
    Copyright © 2010 The Korean Surgical Society
    Original Article

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

    Dong Jin Kim, M.D., Hoon Hur, M.D., Hae Myung Jeon, M.D., Ph.D. and Wook Kim, M.D., Ph.D.
      • Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea.
    • Corresponding author (Email: kimwook@catholic.ac.kr )
    Received October 26, 2009; Accepted January 18, 2010.

    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.

    Keywords
    Gastric cancer; Lower esophageal sphincter; Jejunal pouch interposition

    Figures

    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.

    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.

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

    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.

    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.

    Tables

    Table 1
    Clinicopathological characteristics

    Table 2
    Operative outcomes

    Table 3
    Postoperative morbidity

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