| Objective: In recent years, the Adenocarcinoma of esophagogastricjunction（AEG） incidence with gradual increase and the comprehensivetreatment of surgical excision remains the main treatment. Due to the complexpostoperative complications and the non-obvious advantage5-year survivalrate of the transthoracic gastrectomy treatment of Siewert Ⅱ/Ⅲtype theAEG, making the transabdominal approach gradually accepted.Transabdominal total gastrectomy has been widely used as a standard methodin clinical practice, however postoperative severe or even disabling symptomsdraw the researchers widely concern. With the increasing understanding ofAEG, studies have found that transabdominal proximal gastrectomy resectionand total gastrectomy can achieve the same therapeutic effect with locallyadvanced AEG radical. The most common gastrointestinal reconstructionmethod in the past is proximal gastrectomy postoperative esophageal remnantstomach stapling. However the esophageal gastric remnant anastomosis bringsserious esophagitis reflux making digestion road reconstruction methods needto be improved urgently. Our previous studies have shown: radical proximalgastrectomy with improved jejunal interposition anastomosis does not increasecomplications significantly and can significantly reduce esophagitis reflux,moreover, the long-term survival rate is not inferiority than total gastrectomyand can improve the patients’ life quality compare with subtotal gastrectomyesophageal remnant stomach end side anastomosis and total gastrectomyesophagus jejunum Roux-en-Y anastomosis.This study basis on previous work continue the study of the effects ofjejunal interposition on postoperative gastrointestinal anti-reflux capacity,emptying ability, serum gastrointestinal hormone level, prognostic nutritional status and quality of life, etc. In order to provide further guidelines for theSiewert Ⅱ/Ⅲtype esophagogastric junction adenocarcinoma.Materials and methods:658cases Siewert Ⅱ/Ⅲtype AEG underwentradical treatment between January2008and June2012were selected from theFourth Hospital of Hebei Medical University and clinical data were analyzed.Depending on the surgery type all the patients were divided into the followingthree groups: group A: radical proximal gastrectomy, the improved jejunalinterposition group (221cases,176men and45females), B Group: radicalproximal gastrectomy resection the the esophageal remnant stomach sideanastomosis group (199cases,160men and39females), C Group: radicaltotal gastrectomy esophagus, Roux-en-Y anastomosis group (238cases, male190men and48women). Between the three groups the basic characteristics ofthe data (such as the number, gender, age, etc.) are similar to ensure thebalance of non-research factors. Group A is experimental group compare withthe other two groups (B, C). Data including the24-hour ambulatoryesophageal PH value monitoring6months after surgery, the maximum amountof drinking water recovery after surgery, gastric emptying half-time, beforeand after surgery serum gastrointestinal hormone, Gastrin (GAS), Motilin(MTL), Cholecystokinin (CCK), Somatostatin (SS) content changes,preoperative and postoperative6months nutritional indicators, and otheraspects of quality of life after the difference were analyzed. Clinical evaluationas follows:124-hour ambulatory esophageal PH value monitoring⑴acid refluxtotal time the percentage,⑵total reflux total time percentage.2Maximum recovery rate of water intake:6months after the maximumamount of drinking water/preoperative maximum amount of drinking water(%).3Gastric emptying test:the time of gastric half-emptying after6months.4Gastrointestinal hormone:Normal subjects and patients, respectively,one week after surgery and postoperative serum gastrin after6months Gastrin(GAS), Motilin (MTL), Cholecystokinin (CCK), Somatostatin (SS) content （pg/ml).5Evaluation of the nutrition⑴before surgery, after1week and6monthsafter surgery blood nutrition indicators (hemoglobin of Hb, total protein TP,albumin ALB),(2) the prognostic nutritional index (PNI), PNI=10×serumalbumin protein (ALB: g/dl)+0.005×total lymphocyte count (LY:/mm3),⑶weight.6Evaluation of quality of life⑴gastroesophageal reflux symptoms score(Visick score),(2) gastrointestinal symptom score (GSRS).The test data is processed using SPSS17.0statistical software, P <0.05was considered statistically significant difference.Results:124-hour ambulatory esophageal PH monitoring results:1.1Compare total reflux time percentage of PH <4between group A andgroup B: Group A:(2.40±0.92)%; Group B:(27.86±9.10)%, there is asignificant difference (P<0.05).1.2Non-acidic reflux total time percentage between group A and group C:group A:(3.74±1.29)%; group C:(9.58±0.98)%, there is a significantdifference (P<0.05).2The maximum amount of drinking water intake recovery pre-andpostoperative: Group A the mean value of recovery percentage is (91.71±33.06)%; group B (87.02±20.50)%and groups C with the mean recoverypercentage of (66.57±8.22)%. Group A is better than the other two groups(P<0.05).3Postoperative gastric emptying: three groups of patients with gastrichalf-emptying time: Group A (34.92±11.58) min, Group B (65.25±7.55)min, Group C (13.8±6.84) min. Compared with group B and C there is asignificant difference among the two groups (P<0.05).4Gastrointestinal hormones4.1Serum gastrointestinal hormone comparison between surgical groups7days preoperative and6months4.1.1GAS:①Preoperative values: A, B, C, three groups had no significant difference.②the value of seven days preoperative: group A lower than group Band the difference has no significant difference (P>0.05); A group higher thangroup C, and the difference has statistically significant (P<0.05); B grouphigher than group C, the difference has statistically significant (P<0.05).③6months postoperatively value: Group A higher than group B, the difference hasstatistically significant (P<0.05); Group A higher than in the group C and thedifference has statistically significant (P<0.05); group B higher than the Cgroup, the difference has statistically significant (P<0.05).4.1.2CCK:①Preoperative values: A, B, C three groups have no significantdifference.②seven days postoperative value: A, B, C three groups have nosignificant difference.③postoperatively6months value: Group A lower thangroup B, and the difference has statistically significant (P<0.05); A grouplower than group C and the difference has statistically significant (P<0.05);group B higher than group C, the difference has statistically significant(P<0.05).4.1.3SS:①Preoperative values: A, B, C three groups have no significantdifference.②postoperative seven days value: A, B, C three groups have nosignificant difference.③postoperative6months value: A group higher thangroup B, and the difference has statistically significant (P<0.05); Group Ahigher than group C, and the difference has statistically significant (P <0.05);difference between group B and group C has no significant difference (P<0.05).4.1.4MTL:①Preoperative values: A, B, C three groups have no significantdifference.②postoperative seven days value: A, B, C three groups have nosignificant difference.③postoperative6months values: A, B, C three groupshave no significant difference.4.2Compare normal group with the preoperative surgery groups4.2.1GAS: A, B, C three groups higher than the normal group, the differenceswas significant (P<0.05).4.2.2CCK: A, B, C three groups compared with the normal group, thedifferences have no significance (P>0.05). 4.2.3SS: A, B, C three groups were higher than the normal group, thedifferences have significance (P <0.05).4.2.4MTL: A, B, C three groups higher than the normal group, the differenceshave significance (P <0.05).4.3gastrointestinal hormones change during each period of the surgery:①GAS: preoperative7and postoperative7days and6months values showed adecreasing trend; Group A postoperative6month value closer to normalvalues.②CCK: preoperative7and postoperative7days and6months valuesshowed an increasing trend; Group A postoperative6month value closer tonormal values.③SS: preoperative7and postoperative7days and6monthsvalues showed a decreasing trend; Group A postoperative6month value closerto normal values.④MTL: preoperative7and postoperative7days and6months values showed a decreasing trend; difference between the three groupshave no significant difference.5nutrition indicators5.1A group and B group:①group A: postoperative6months, Hb, ALB, TP, PNI value returned tothe preoperative level (P>0.05), the weight close to the preoperative levels.Group B: postoperative6months, Hb value is still lower than the preoperativevalue (P<0.05), ALB, TP, the PNI value and preoperative value has notsignificant difference (P>0.05), but the weight is still lower than that levelbefore.②A group of after6months Hb values reached preoperative levels,while group B the Hb value has not yet returned to the preoperative level twosignificant differences (P<0.05).③Group A weight gain postoperative6months is higher than that in group B, and there is a significant difference(P<0.05).5.2Group A compared with group C:①group A postoperative6months, Hb value basically returned topreoperative levels,②while group C Hb value is lower than the preoperativevalue,and there is a significant difference (P <0.05).③6months after surgeryweight gain in group A than in group C, there is a significant difference (P> 0.05).6Evaluation of postoperative life qualit6.1Visick scores of Ⅰ-Ⅳ: Group A:88.70%,9.95%,1.35%and0%. GroupB:6.53％，70.35％，19.10％and4.21%. Group C:83.20%,14.28%,1.68%and0.84%. Difference between group A and group B has statisticallysignificance (P<0.05), the difference between group A and group C groupsshowed no significant difference (P>0.05).6.2The mean values of GSRS rating system were: A group of2.30±1.67,group B4.66±1.89in group C3.65±1.63. Group A better than group B andgroup C (P <0.05).Conclusion:1Proximal gastrectomy: improved jejunum interposition technique caneffectively reduce esophagitis reflux and improve acid resistant and non-acidreflux.2The proximal gastrectomy: patients with improved jejunuminterposition surgery in stable state, gastrointestinal hormones Gas, CCK andSS compared to the level of preoperative despite reduced or increased, butcloser to the normal value; MTL level has no significant difference withstomach esophageal end side anastomosis group and esophagus Roux-en-Yanastomosis group. Compared with normal human, the GAS, SS and MTLlevels in the serum of gastric cancer patients have elevated.3Proximal gastrectomy: improved jejunal interposition surgery patientsrecovered rapidly and food intake increased significantly and recovered topreoperative levels rapidly. Gastric emptying close to normal physiologicalconditions, the prognosis quality of life improved significantly. |
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