Long-term clinical and endoscopic assessment after total gastrectomy for cancer

Summary

Progressive malnutrition has been reported as a long-term consequence of total gastrectomy (TG), possibly related to the mode of reconstructing the intestine. In reviewing our personal experience (1975-Sept. 91), we attempted to correlate the reconstructive technique used with the subsequent course of the patient.

A consecutive series of 62 TGs (59 adenocarcinomas, 3 lymphomas) in 38 males and 24 females 59±11 (m Mean±SD) years old was reviewed. Preoperative and “follow-up” evaluations, including upper gastrointestinal series and/or endoscopic examination, complete blood count, serum and liver biochemistry profiles, serum iron and plasma transferrin, oral GTT, USG or CT scan, actual and ideal body weight (IBW Life Extension Institute of New York), and “performance status” assessments, were prospectively documented. The follow-up symptoms were classified as per Cuschieri's scoring system. The endoscopic esophageal mucosa assessments were documented as well. Among 56 patients surviving operation, 34 were available, without tumor recurrence, for long-term (12–132 months) evaluation. A Roux-en-Y loop reconstruction had been performed in 23, 5 with a Hunt-Lawrence pouch; an isoperistaltic, esophagoduodenal, jejunal interposition (IR) was performed in 9, 4 with a Kock pouch; and an omega loop reconstruction was performed in 2. A 60–70-cm-long jejunal limb was always utilized. Statistical analyses, by Student t and equality of medians (two-sample Wilcoxon rank-sum) tests, were obtained where suitable and appropriate.

Progressive malnutrition was observed in both patients with omega loop reconstructions, both displaying persistent grade II esophagitis, restricting food intake ability. This was reversed after reoperation, converting the omega into a Roux-en-Y loop, enabling both of them to regain IBW. Roux-en-Y and IR loops were equally efficient in preventing alkaline esophagitis. Of the remaining patients, 29 were able to regain IBW regardless of reconstructive method utilized and of whether or not a reservoir had been constructed.

We conclude: (1) Avoiding an indicated TG due to fears of malnutrition is unwarranted. (2) A simple Roux-en-Y is the most suitable method in most instances. (3) Because of its potentially higher morbidity risks, it is hard to justify performing an IR, on a routine basis. (4) The “benefit” of a Hunt or a Kock reservoir is not supported by our observations. (5) An omega loop cannot be recommended.