Total gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of hepatic vagus branch and lower esophageal sphincter for T2 gastric cancer without lymph node metastasis

Abstract

Background/aims: In order to improve postgastrectomy disorders of patients with T2 (MP or SS) gastric cancer without lymph node metastasis, which mainly locates in the middle third of stomach, we have performed a total gastrectomy preserving both hepatic vagus branches and the lower esophageal sphincter as a function-preserving surgical procedure.

Methodology: In the present study, the application criteria and points of the technique are outlined, and postoperative quality of life is clinically investigated. Twenty-four subjects who underwent this surgical operation (group A; 16 men and 8 women subjects aged 46 to 73 years, mean age 62.2 years) were interviewed regarding appetite, weight loss, reflux esophagitis, dumping syndrome, and microgastria. Cholelithiasis following total gastrectomy was also checked by abdominal ultrasonography. Group A was compared with 26 cases of conventional total gastrectomy with D2 lymphadenectomy, excision of lower esophageal sphincter, total vagotomy, and single jejunal interposition (B group; 19 men and 7 women subjects aged 42 to 75 years, mean age 64.8 years). Application criteria of the technique: Included were cases with T2 cancer of N0 mainly localizing at the middle-third of the stomach which was 4 cm or further in distance from the oral-side margin of the cancer to the esophagogastric mucosa junction. Points of the technique: In lymphadenectomy, hepatic branches of the vagal nerve only preserved. To preserve lower esophageal sphincter, the abdominal esophagus was severed at the level of His angle to the longitudinal axis of the esophagus. Substitute stomach was created as a 15-cm jejunal pouch with a 5-cm-long jejunal conduit for isoperistaltic movement.

Results: In group A the food ingestion rate was significantly greater than that of group B (P<0.001) at 6 months and 2.0 years after operation, with no reflux esophagitis or dumping syndrome being noticed at 2.0 years after operation. In group B, loss of appetite 2.0 years after operation was significantly higher than that in group A (P<0.01). In addition, symptomatic reflux esophagitis (heartburn, dyspepsia, regurgitation) developed more significantly in group B than in group A (P<0.05). For food ingestion per time, group B was significantly delayed compared with group A (P<0.05). Body weight loss in group B was significantly higher than that in group A (P<0.01). Postgastrectomy cholelithiasis was detected significantly more in group B than in group A (P<0.05).

Conclusions: These results suggested that the surgical technique proposed is safe and leads to a satisfactory symptomatic and nutritional result, and that this procedure is a function-preserving gastric surgery appropriate to prevent postgastrectomy disorders of subjects for T2 gastric cancer without lymph node metastasis, mainly located in the middle-third of stomach.