A novel surgical procedure of vagal nerve, lower esophageal sphincter, and pyloric sphincter-preserving nearly total gastrectomy reconstructed by single jejunal interposition, and postoperative quality of life.
OBJECTIVE
For early gastric cancer total gastrectomy (TG) has so far been essentially unavoidable. We performed the nearly TG reconstructed by single jejunal interposition preservation of the vagal nerve, lower esophageal sphincter (LES) and pyloric sphincter (D1 or D2 lymph node dissection, curability A) as a function-preserving surgical technique (i.e. NTG) to improve postoperative quality of life (QOL). In this report, the application criteria and points of the technique are outlined. QOL in patients after NTG was also compared with those after TG.


METHODS
Sixteen subjects who underwent NTG (12 men and 4 women subjects at age 30 to 70 years, mean 55.6 years) were interviewed to inquire about abdominal symptoms and compared with 20 patients after conventional TG (excision with D2 lymph node, radical curability A) reconstructed by single jejunal interposition without preserving the vagal nerve, LES, and pyloric sphincter (i.e. TGI; 14 men and 6 women at age 26 to 70 years, mean 54.8 years). The former was named group A and the latter group B. Included were cases with early cancer localizing at the upper third and middle stomach, 2cm or further in distance from oral-side margin of the cancer to esophagogastric mucosal junction; and 3.5cm or further in distance from anal-side margin of the cancer to the pyloric sphincter. In excision with the lymph node, hepatic and celiac branches were preserved. To preserve LES, the abdominal esophagus was completely preserved. The pyloric antrum was also preserved at 1.5cm from the pyloric sphincter. The substitute stomach was created as a 30-cm-long single jejunal segment having orthodromic peristaltic movement.


RESULTS
The operative procedure in group A significantly improved postoperative gastrointestinal symptoms such as appetite loss (p=0.0004), weight loss (p=0.0369), reflux esophagitis (RE) (p=0.0163), early dumping syndrome (p=0.0163), endoscopic RE (p=0.0311), and postgastrectomy cholecystolithiasis (p=0.0163) compared with group B. Oral intake per one meal 5 years after operation compared with that before operation was better in group A than in group B (p=0.0703). Postoperative epigastric fullness was significantly detected in group A compared with group B (p=0.0072).


CONCLUSIONS
The proposed surgical technique of NTG is a function-preserving surgery appropriate to improve QOL of subjects with early gastric cancer. There was a defect in this technique of postprandial feeling of epigastric fullness. We think that a gut motility improvement agent is necessary to improve postprandial epigastric fullness after NTG.
Tomita
Ryouichi
R
Department of Surgery, Nippon Dental University School of Dentistry at Tokyo, Nippon Dental University Hospital, Japan.
D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D015331:Cohort Studies; D004377:Dumping Syndrome / Q000517:prevention & control; D004941:Esophagitis / Q000517:prevention & control; D004943:Esophagogastric Junction / Q000294:innervation / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000517:prevention & control*; D011708:Pylorus / Q000294:innervation / Q000502:physiology; D011788:Quality of Life; D013270:Stomach / Q000294:innervation*; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014630:Vagus Nerve / Q000502:physiology