Simple Versus Double Jejunal Pouch for Reconstruction after Total Gastrectomy

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1 Simple Versus Double Jejunal Pouch for Reconstruction after Total Gastrectomy Maria A. Gioffre Florio, MD, Marcello Bartolotta, MD, Joseph C. Miceli, MD, Giuseppa Giacobbe, MD, Francesco P. Saitta, MD, M. Teresa Paparo, MD, Biagio Micali, MD, Messina, Italy BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique ( group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop ( group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction. Am J Surg. 2000;180: by Excerpta Medica, Inc. From the Department of General Surgery, University Hospital, University of Messina, Messina, Italy. Requests for reprints should be addressed to Maria A. Gioffre Florio, MD, Chirurgia Generale, Pad. C, IV piano, Policlinico Universitario, Messina, Italy. Manuscript submitted December 9, 1999, and accepted in revised form May 17, Total gastrectomy may result in early satiety, malabsorption, malnutrition, and weight loss. The increased incidence of postgastrectomy syndromes is a cause of controversy in choosing the method of reconstruction after total gastrectomy. The most common method of alimentary reconstruction, esophagojejunostomy by the Roux-en-Y technique, 1 may lead to significant symptoms such as retrosternal pyrosis, dysphagia, nausea, vomiting, dumping, and diarrhea. 2 To reduce their incidence, various reconstructive methods have been proposed. The double lumen jejunal pouch anastomosed to the esophagus, and Roux-en-Y anastomosis distal to this (Hunt-Lawrence reconstruction), is described as having good outcome assessments. 3 8 To further improve the quality of life and reduce nutritional problems in patients who undergo total gastrectomy, a modification of the Hunt-Lawrence method adopting the construction of a second inframesocolic reservoir or double pouch was developed and studied. The aim of this study was to compare long-term results of quality of life and nutritional status in patients with a digestive single pouch () with a double pouch () reconstruction following total gastrectomy. PATIENTS AND METHODS From 1991 to 1995, 105 patients with gastric carcinoma have been managed in our department of surgery. All were diagnosed with clinical, endoscopic, and histological examinations. Staging was completed by ultrasonography and computed tomography (CT) scan. Of these, 60 patients were excluded from our study because of advanced disease, often with liver and/or peritoneal spread, and had palliative surgery and/or chemotherapy. The other 45 patients (Tables I and II) entered our protocol after approval by the Ethics Committee. At admission, a preoperative randomization for type of reconstruction was performed with the use of a table of random numbers, 9 where a number was assigned to each patient. All patients with even numbers were entered into the standard Hunt-Lawrence single pouch group (), and all patients with odd numbers entered the modified double pouch group (). Type of reconstruction of each patient was kept blind to the surgeon before surgery and revealed only after total gastrectomy resection. At surgery, 4 patients of group were converted to a palliative treatment followed by chemotherapy because of peritoneal metastatic implants, not evident on preoperative evaluation at the time of randomization. Except for these patients now excluded from the randomized study, all study patients underwent total gastrectomy with extended (D2) lymph node dissection. The reconstruction was completed according to the single pouch technique in 18 patients ( group), while in the remaining 23, the technique was modified with the construction of a second pouch in the distal portion of the jejunal loop ( group). Our modified double pouch reconstruction (Figure 1) provides isolation of the second-third jejunal loop in order by Excerpta Medica, Inc /00/$ see front matter All rights reserved. PII S (00)

2 TABLE I Demographics for 41 Patients Who Underwent Total Gastrectomy and Reconstruction with Single Pouch () or Double Pouch () Total Sex 14M:4F 18M:5F 32M:9F Median age (range) 55.5 yrs (49 61) 61.8 yrs (57 81) 66.1 yrs (49 81) Type of tumor Adenocarcinoma (100%) Intestinal 44.4% 47.8% 46.3% Diffuse 55.6% 52.2% 53.7% M male; F female. to obtain sufficient length and mobility of the mesentery for subsequent transposition to the supramesocolic region. The jejunum is divided with a linear stapler (Proximate Reloadable Linear Cutter TLC 55; Ethicon, Inc.). The limb is placed in a retrocolic fashion. Anastomosis of the esophagus and jejunum is performed with a circular stapler (Proximate ILS Curved Intraluminal Stapler 25-29; Ethicon, Inc.), introduced through an enterotomy in the jejunal loop. After having applied a purse-string suture on the divided end of the esophagus, end-to-side esophagojejunostomy is performed by circular stapler and fixed to the diaphragmatic crura with 2-3 Vycril. The proximal pouch is constructed by a running suture on the antimesenteric borders of jejunum, brought parallel in a upsidedown J fashion. The distance between the inferior margin of the proximal pouch and esophagojejunal anastomosis is about 6 to 8 cm. When the double pouch technique is used, the second pouch is constructed by a linear stapler (Proximate Reloadable Linear Cutter TLC 75; Ethicon, Inc.) between the afferent jejunal loop and the transposed jejunal loop, in the inframesocolic region, at a distance of about 25 cm from the inferior margin of the proximal pouch. Patients were followed up regularly following surgery by CT scan and ultrasound examinations. Follow-up varies from 6 to 60 months with a mean follow-up interval of months. For the purpose of this comparative study, patients were examined by one of the experienced staff members approximately 12 months after surgery, this staff member being blinded to the type of reconstruction employed. These evaluations included assessment of gastrointestinal function, quality of life, body weight maintenance, and various nutritional parameters on laboratory examination (serum albumin, hemoglobin, serum proteins). Endoscopy with biopsy was performed at this time. For symptom evaluation, Cuschieri scores and Visick scores were calculated. 10,11 Statistical analysis of the data was performed by t test for paired data and the chi-square test. Values of P 0.05 were considered as statistically significant. RESULTS One patient in the group (1 of 23, 4.3%) died on the third postoperative day owing to a cerebrovascular accident. Only 1 major nonfatal postoperative complication occurred in the group (4.3%), an esophagojejunal leak that was successfully healed by fasting and total parenteral nutrition. Nine patients were excluded from the comparative study, 4 from the group (3 lost to follow-up and 1 with recurrence of cancer) and 5 were excluded from the group (3 lost to follow-up and 2 developed recurrence during the interval). The patients eligible for the comparative study at the 12-month interval was 77.5% (31 of 40 patients), and the proportion was similar for both the and groups (77.8% for group and 77.3% for group). At follow-up, at 12 months after surgery (Table III), 2 of 17 patients (11.8%) in group described abdominal distention after meals of moderate transient intensity, early satiety, diet restriction, dumping. The remaining patients (15 of 17, 88.2%) had satisfactory gastrointestinal function without any dietary restriction and without or mild specific symptoms. In the group, 5 of 14 patients (35.7%) demonstrated early satiety, postprandial epigastric fullness, pyrosis, diarrhea; and 5 of 14 (35.7%) had satisfactory compliance. The assessment by Visick grading (Table IV) revealed in 3 of 17 patients (17.6%) in the group unsatisfactory digestive functions. In the group, 8 of 14 patients (57.1%) had persistent postprandial symptoms, and 6 of 14 patients (42.9%) had good recovery of digestive functions. At 12 months we observed (Table V) a higher percentage of patients (14 of 17; 82.4%) with body weight increase in comparison with patients (8 of 14; 57.1%). Albuminemia and hemoglobin were increased in a higher percentage of versus patients [respectively, 13 of 17 (76.5%) and 12 of 17 (70.6%) compared with 7 of 14 (50%) and 6 of 14 (42.9%)]. We have seen an increase of serum proteins in 16 of 17 (94.1%) in the group and in 8 of 14 (57.1%) in the group. All postoperative values and mean values of each patient in and groups for weight, albumin, hemoglobin, and total proteins with their significant increase are shown in Table II. Endoscopic examination showed, respectively, in 3 of 17 (17.6%) patients and in 5 of 14 (35.7%) patients a mild esophagitis, but no patient had significant esophageal changes. COMMENTS Total gastrectomy is associated with complex alterations of nutrition and metabolism that are characterized by the loss of important digestive functions, mainly that of reservoir (mixture and coordinated emptying of food in duodenum), secretory (hydrochloric acid, pepsin, gastrin, and somastostatin) that acts directly and indirectly on digestion THE AMERICAN JOURNAL OF SURGERY VOLUME 180 JULY

3 TABLE II Clinical Parameters of Patients* Preoperative Values Postoperative Values W (Kg) Alb (g/dl) Hb (g%) TP (g/dl) W (Kg) Alb (g/dl) Hb (g%) TP (g/dl) Normal Ranges patients Mean SE patients Mean SE * Clinical parameters, ie, weight (W), albumin (Alb), hemoglobin (Hb), and total proteins (TP) before and after (12 months) surgery are given for each patient included in our study. P 0.05, between preoperative and postoperative. P 0.01 between preoperative postoperative. single pound reconstruction; double pound reconstruction. and absorption, and esophageal reflux from loss of the cardia. Even though the most common type of reconstruction, 12 Roux-en-Y esophagojejunostomy, seems to prevent postgastrectomy syndromes, it could interfere with an adequate food intake, 8,13 leading to a lack of body weight recovery. 5,14 Also, if postprandial disturbances seem to have, after Hunt-Lawrence pouch reconstruction, a significantly lower incidence compared with Roux-en-Y patients, 6,16 weight increase in some but not all studies fails to show significant differences between Hunt-Lawrence and Rouxen-Y. 15,16 This seems to indicate that the nutritional state of Hunt-Lawrence patients does not improve in a satisfactory way. A scoring system reflects in a small part a subjective component of evaluation, maintaining, in any way, an accurate gathering method of symptoms by the same examinator. Postgastrectomy symptoms, divided into good, fair, and poor based on Cuschieri scores and on a scale from I to IV according to Visick scores, have clearly demonstrated an increase of life quality in patients compared with patients at 12 months from surgery. A significant increase in weight occurred in 82.4% of patients compared with 57.1% of patients. It is further known that lacking increment of weight is strictly correlated to the caloric intake more than to alimentary malfunction and malabsorption. 5 However, the construction of 26 THE AMERICAN JOURNAL OF SURGERY VOLUME 180 JULY 2000

4 TABLE III Symptomatic Assessment by Cuschieri Grading 12 Months after Surgery in Surviving Patients with Single Pouch () and Double Pouch () Reconstruction Cuschieri Grading Number of Patients Number of Patients Good (0 7) 5 (35.7%) 11 (64.7%) Fair (8 14) 4 (28.6%) 4 (23.5%) Poor (15 21) 5 (35.7%) 2 (11.8%)* *P 0.05 between and. P 0.01 between and. TABLE IV Symptomatic Assessment by Visick Grading 12 Months after Surgery in Surviving Patients with Single Pouch () and Double Pouch () Reconstruction Visick Grading Number of Patients Number of Patients I 5 (35.8%) 11 (64.7%)* II 1 (7.1%) 3 (17.7%) III 7 (50%) 2 (11.8%)* IV 1 (7.1%) 1 (5.8%) *P 0.01 between and groups. Figure. The modified Hunt-Lawrence reconstruction technique. a second pouch would allow a determinate nutritional advantage that reflects in weight increase. In this study, we found that our modified HL method, constructing a second infra-mesocolic pouch, reveals improvement in nutritional status. The nutritional parameters that we have evaluated were serum levels of albumin, hemoglobin, and total proteins. The modifications of these parameters remain more variable long after surgery and are in strict relation with the quantity and quality of food, nevertheless, the nutritional advantages demonstrated by increase in albumin and total protein values seem evident. Certainly, recurrence is in strict connection to any nutritional advantage rather than with the reconstructive technique. This correlates directly to the proceeding digestive parameters that improve proportionally to the diseasefree postsurgical time. In fact, the functional and nutritional follow-up seems to demonstrate that the recurrencefree patients show, at 1 year, a satisfactory recovery of the digestive functions (food intake, weight) and an increase of nutritional parameters. 5 On the contrary, patients who present with recurrence in the first year after gastrectomy do not have any functional and metabolic advantage. 5 Our results indicate that the construction of jejunal pouch, TABLE V Surviving Patients with Single Pouch () or Double Pouch () Reconstruction Showing Efficient Increment of Nutritional Parameters Toward Normal Range and Body Weight Increase 12 Months after Surgery Number of Patients Number of Patients Weight 8 (57.1%) 14 (82.4%)* Albumin 7 (50%) 13 (76.5%)* Hemoglobin 6 (42.9%) 12 (70.6%) Total proteins 8 (57.1%) 16 (94.1%) *P 0.05 between and groups. P 0.01 between and groups. single or double, allows a consistent nutritional rise regarding, in particular, patients with reconstruction. Patients with technique compared with patients demonstrate more significant recovery of the digestive function, more determined reduction of postprandial symptoms, and a significant improvement of quality of life. Our study seems to indicate that when a second pouch is applied, an increase in specific nutritional values toward normal range and a higher percentage of patients with major nutritional performance are obtainable compared with patients. In conclusion, the present study seems to confirm that a double gastric substitute, with a good probability of disease-free survival until 1 year, leads to better outcome assessments compared with one gastric substitute. When our reconstructive technique indicates the use of a double pouch, life quality (in terms of functional results THE AMERICAN JOURNAL OF SURGERY VOLUME 180 JULY

5 and patient satisfaction) and nutritional recovery seem to significantly improve. However, the mechanism for this improvement is still not clear. One reason is probably that our very long roux-y type of second pouch may delay transit more effectively, but no data are yet available. REFERENCES 1. Heberer G, Teichmann RK, Kramling HJ, et al. Results of gastric resection for carcinoma of the stomach: the European experience. World J Surg. 1988;12: Mathias JR, Fernandez A, Sninsky CA, et al. Nausea, vomiting and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology. 1985;88: Hunt CJ. Construction of food pouch from segment of jejunum as substitute for stomach in total gastrectomy. Arch Surg. 1952;64: Lawrence Jr W. Reservoir construction after total gastrectomy. Ann Surg. 1962;155: Troidl H, Kusche J, Vestweber KH, et al. Pouch versus esophagojejunostomy after total gastrectomy: a randomized clinical trail. World J Surg. 1987;11: McAleese P, Calvert H, Ferguson WR, et al. Evaluation of gastric emptying time in the J pouch compared with a standard esophagojejunal anastomosis. World J Surg. 1993;17: Heimbucher J, Fuchs KH, Freys SM, et al. Motility in the Hunt-Lawrence pouch after total gastrectomy. Am J Surg. 1994; 168: Nakane Y, Okumura S, Akehira K, et al. Jejunal pouch reconstruction after total gastrectomy for cancer. A randomized controlled trial. Ann Surg. 1995;222: Smart JV. Elementi di statistica medica. Milano: Centro G. Zambon, University of Milano; 1969: Cuschieri A. Jejunal pouch reconstruction after total gastrectomy for cancer. Br J Surg. 1990;77: Pope CE. The quality of life following antireflux surgery. World J Surg. 1992;16: Siewert JR. Magencarcinom. In: Allgower M, Harder F, Hollender LF, et al, eds. Chirurgische Gastroenterologie. Berlin: Springer Verlag; 1981: Bradley EL, Isaacs J, Hersh T, et al. Nutritional consequences of total gastrectomy. Ann Surg. 1975;182: Braga M, Zuliani W, Foppa L, et al. Food intake and nutritional status after gastrectomy: results of a nutritional follow-up. Br J Surg. 1988;75: Bozzetti F, Bonfanti G, Castellani R, et al. Comparing reconstruction with Roux-en-Y to a pouch following total gastrectomy. J Am Coll Surg. 1996;183: Micali B, Gioffre MA, Saitta FP, et al. Jejunal pouch reconstruction after total gastrectomy. A long-term evaluation. Eur J Surg Oncol. 1996;22: THE AMERICAN JOURNAL OF SURGERY VOLUME 180 JULY 2000