The Comparison Of Two Kinds Of Digestive Tract Reconstruction After The Whole Gastrectomy

Objective: To compare two kinds of reconstruction of alimentary canal impact on patients' life quality after the total gastrectomy. To discuss the reasonable way of reconstruction of alimentary canal, and to improve the patients' life quality. Methods: To analysed retrospectively 65 patients who has been after the total gastrectomy. 31 patients underwent the P-shaped Roux-en-Y esophagojejunostomy and 34 patients underwent the Lahey's anastomosis. The clinical data, including complications, nutritional status, markers of blood-trophogy, were compared between the two groups. Results: The P-shaped Roux-en-Y esophagojejunostomy which can improve postoperative quality of life and nutritional status is easier to control. The time of operation is shorter and the postoperative complications are less. Conclusion: The P-shaped esophagojejun-ostomy is a better reconstruction procedure after total gastrectomy. Gastric cancer is one of the most common malignant digestive system cancers. This has the highest incidence among malignant tumors, and its mortality rate runs high up to the third place. At present, surgical operation is widely considered to be the primary method to fight with gastric cancer, and also the only way might have chance to cure this cancer. The total gastrectomy is a common method to eradicate gastric cancer. In a general way, patients with following symptoms are strongly recommended to take total gastrectomy: 1. Cancer swelling spreads to two or more regions, 2. The metastasis of second station lymph nodes spread, 3. Gastric cancer soaks and spreads up to half or two third of gastric wall, 4. Cancer swelling is located only in one region but some precancerous pathological changes, such as atrophic gastritis and severe metaplasia, have been found in other regions, 5. More than one lesions, the main lesion and the accessory lesion are located respectively at the distal end and the proximal end of stomach, 6. The whole lesser curvature has been covered and soaked by cancer, 7. And remnant gastric cancer.However, the patients who take total gastrectomy will suffer malnutrition, losing weight, and other sequelae due to the disappearance of gastric cavity, appetite decline, rushed food voidance, and bad absorption caused by inefficient mix with gastric juice. Since 1897 Schlatter operated the first successful total gastrectomy, many doctors from all over the world have made great efforts to create more than 70 methods of alimentary canal reconstructions. Even though some new reconstructive procedures come out every year, which way is the most reasonable is still being hot discussed among our surgeons. In the recent 10 years, the death rate of total gastrectomy has declined significantly, and the long-dated sequelae, like postoperative nutrition barrier, have been overcome through kinds of alimentary canal reconstructions. At the same time, the ratio of proximal gastric cancer starts climbing, so that more and more experts call out for a better procedure. In China, the total gastrectomy is about 10% ~ 15% of all cases of gastric cancer. To prevent and reduce postoperative syndromes, increase postoperative nutrition absorption, and enhance the quality of postoperative life, which reconstructive method combined with total gastrectomy shall we choose becomes especially important.There are various ways of reconstructions after total gastrectomy. Anatomically, most of the current anastomosis were derived from classical Roux-en-Y anastomosis and jejunal interposition. Physiologically, there are four main types of procedures: 1. Food passes through duodenum without reconstructing storage sac, 2. Food passes through duodenum, and the storage sac is reconstructed, 3. Food bypasses the duodenum without reconstructing the storage sac, 4. Food bypasses the duodenum, but the storage sac has to be reconstructed. Ordinarily speaking, the ideal alimentary canal reconstructions of post total gastrectomy should meet the following four requirements: 1. Reconstruct a food storage sac, and slower the movement of chyme to small intestine, 2. Prevent the duodenum juice reflux to esophagus, 3. Ensure the digested food can pass through duodenum,4. Simple, safe operation with small wound and low mortality rate. Because of the unique physiological functions of stomach, there is no other organ can replace it. Total gastrectomy will combine with more or less postoperative complications, such as reflux esophagitis, early or late symptoms of dumping syndrome, bad digestion and absorption, diarrhea, losing appetite, stuffing or hurting after meal, etc. All those symptoms are called post gastrectomy syndrome. If patients suffer these sequelae too long, they will get anemia, or bone metabolism barrier. To prevent the above complications, the methods to replace stomach after total gastrectomy is a very important surgical project. P-shaped esophagojejunostomy is a common method to reconstruct alimentary canal. The detailed procedures are clear out lymph nodes during operation, excise the whole stomach, close the remaining end of duodenum, divide the jejunum 20 cm from the ligament of Treitz, cut the omentum and the vessels around, anastomose the esophagus and the jejunum front to or back to transverse colon, and then anastomose the proximal end and the distal end of jejunum to create a P-shaped ring, and last anastomose the proximal end of remaining jejunum and distal jejunum 30 ~ 40cm lower the previous anastomosis. Now the reconstruction of alimentary canal is finished. For evaluating the postoperative effect of P-shaped Roux-en-Y esophagojejunostomy, there are 65 cases, between 1993 –2004 in the General Surgery of JiLin University First Hospital, have be collected and analyzed. 54 of the 65 are males, and the rest 11 are females. The ratio between the two genders is 4.9 : 1. These patients'ages arrange from 34 to 80 years old, and average age is 51.5. All the cases took barium meal, diagnosed by gastroscopy and pathological examination. They are histologically divided into 6 groups: 3 cases of well-differentiated adenocarcinoma, 5 cases of middle-differentiated adenocarcinoma, 42 cases of poorly-differentiated adenocarcinoma, 5 cases of non-differentiated adenocarcinoma, 3 cases of non-Hodgkin's lymphoma, and 7 cases of remnant gastric cancer. By clinic pathology they are also divided into 4 groups: stage Ⅱ-11 cases, stage Ⅲa –18 cases, stage Ⅲb –22 cases, and stage IV -14 cases. These 65 had undergone the P-shaped Roux-en-Y esophagojejunostomy and the esophagus-jejunum anastomosis with jejunum-jejunum Braunn anastomosis (Lahey's anastomosis). Then all these clinical data were compared and analyzed by the ways of reconstructions, and the quality of postoperative life styles.Trough close observation of during before and after operation and frequent tracking visit after discharge, the patients had been kept eyes on complications just after operations, complication long after operation, diarrhea, tympanites, inappetence, reflux esophagitis, and dumping syndrome etc. Some lab data had also been considered, such as weight, hemoglobin, TP, and Lymph C etc. Combined with above two groups of data, the situation of these patients were divided by Visick Scale into 4 status: Ⅰis basically normal, Ⅱis with mild syndrome, Ⅲis with severe syndrome, and Ⅳis intolerant. Then we got a nutritional index PNI, PNI = 10 + 0.005 (Lymph C). The above result shows that P-shaped Roux-en-Y esophagojejunostomy owns the following advantages: 1. P-shaped Roux-en-Y esophagojejunostomy is the better one to fit anatomy structure. And after about half year of surgery, the P-shaped ansa intestinalis will extend and replace the stomach on some certain functions nicely. 2. After total gastrectomy, the establishment of a storage sac is strongly recommended to reduce postoperative complications, and to enhance patients'postoperative life. Based on above expatiation P-shaped Roux-en-Y esophagojejunostomy is relatively more ideal method of alimentary canal reconstruction.