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Documentos de Profesional
Documentos de Cultura
During the latter half of the 20th century, there was a decline
in the incidence of the endemic (intestinal) form of gastric Figure 1. Perioperative photograph taken during a total gastrectomy
carcinoma in the USA.1 By contrast, tumours arising from operation.
the gastro-oesophageal junction and distal oesophagus—
which are associated with a type of oesophageal metaplasia intestinal tract.6,7 These processes should result in better
known as Barrett’s epithelium—have increased in calcium and iron absorption with improved lipid and
incidence.2 Despite its decline, however, the endemic form of protein digestion.8 In addition to preservation of the
gastric cancer is one of the most common causes of death duodenal passage, there should be no loop of jejunum
from malignant disease.3 There are an estimated 798 000 extending out of the oesophageal-intestinal passage. This
annual cases worldwide, 21 900 of which occur in the USA. method, in theory, should maximise and stimulate the
Total gastric resection and the selection of the remaining intestinal tract for caloric absorption in these
appropriate operation for the reconstruction of the passage commonly malnourished patients.
between the oesophagus and the intestine is controversial Second, the formation of an appropriate replacement
(figure 1). Many different types of reconstruction after total gastric reservoir, to simulate pre-operative gastric volume, is
gastrectomy have been proposed, but a great deal of research considered important. Construction of an enteric pouch—
is still being done to validate the potential advantages of eg, the Roux-en-Y, double jejunum, and aboral—is thought
various procedures. The main focus of such reconstruction to enable the patient to consume larger, more customary,
should be to retain the nutritional status and quality of life of and satisfying meals.4,6 A pouch should therefore improve
the patient, and also to achieve similar function to that of a the patients’ quality of life, allow them to ingest more
normal gut. In this review, we discuss the prospective calories, and help to prevent malabsorption and weight loss.
randomised studies of gastrointestinal reconstruction after Reconstructive procedures after total gastrectomy take
total gastrectomy. these considerations into account, and can be classed as:
● Duodenal passage and no pouch—reconstruction with
Considerations for reconstruction preservation of the duodenal passage but no pouch
The reconstruction of the intestinal tract after complete formation—eg, jejunal interposition.9
gastric resection requires the restoration of the enteric flow ● Duodenal passage with pouch—reconstruction with
between the oesophagus and small intestine. More than 60 both preservation of the duodenal passage and enteric
techniques have been described since Schlatter reported the pouch—eg, jejunal interposition pouch, -double tract,
first successful total gastrectomy with reconstruction in jejunal double tract, and the Ulm pouch (figure 2).6,7,9–12
1897.4,5 These different methods of reconstruction
incorporate two basic concepts.
ACC and NJE are at the Department of Surgery, The University of
First, there is importance placed on the preservation of
Illinois at Chicago, USA.
the duodenal passage. It has been hypothesised that passage
Correspondence: Dr N Joseph Espat, Department of Surgery,
of food across the duodenum, resulting in the mixture of University of Illinois at Chicago, 840 South Wood Street (M/C 958),
chyme with biliary and pancreatic secretions, aids in Chicago, IL 60012, USA. Tel: +1 312 355 1493.
digestion, absorption, and the stimulation of the remaining Fax: +1 312 355 1987. Email: Jespat@uic.edu
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Review Reconstruction after total gastrectomy
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Reconstruction after total gastrectomy
Review
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Review Reconstruction after total gastrectomy
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Reconstruction after total gastrectomy
Review
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Review Reconstruction after total gastrectomy
References
Search strategy and selection criteria
1 Gunderson L, Donohue JH, Burch P. Stomach. In: Abeloff M,
Data for this review were identified by searches of Medline, Armitage J, Lichter A, Niederhuber JE (Eds). Clinical Oncology.
Current Contents, PubMed, and references from relevant New York: Churchill Livingstone, 1995: 1209–41.
articles with the search terms “total gastrectomy”, 2 Wu-Williams AH, Yu MC, Mack TM. Life-style, workplace, and
“reconstruction and total gastrectomy”, “total gastrectomy stomach cancer by subsite in young men of Los Angeles County.
Cancer Res 1990; 50: 2569–76.
and reconstruction” and “randomised clinical trial”. Only 3 Rosin R. Tumors of the stomach. In: Zinner M, Schwartz S, Ellis H
papers published in English between 1987 and 2002 were (Eds). Maingot’s Abdominal Operations, 10th edn. Stamford:
included. Appleton & Lange, 1997: 999–1028.
4 Kalmar K, Cseke L, Zambo K, Horvath OP. Comparison of quality
of life and nutritional parameters after total gastrectomy and a new
type of pouch construction with simple Roux-en-Y reconstruction:
Conclusion preliminary results of a prospective, randomized, controlled study.
Dig Dis Sci 2001; 46: 1791–96.
On the basis of the data from prospective clinical studies we 5 Schlatter C. A unique case of complete removal of the stomach:
use the technique of jejunal pouch with a Roux-en-Y successful oesophagoenterostomy recovery. Medical Research 1897;
oesophago-jejunostomy reconstruction (or Hunt-Lawrence- 52: 909–14.
Rodino pouch) after total gastrectomy. Furthermore, we 6 Schwarz A, Buchler M, Usinger K, et al. Importance of the
duodenal passage and pouch volume after total gastrectomy and
prefer to place a feeding jejunostomy tube at the time of the reconstruction with the Ulm pouch: prospective randomized
procedure to optimise postoperative nutrition (figure 5). clinical study. World J Surg 1996; 20: 60–66.
Our choice of reconstruction is based on several 7 Fujiwara Y, Kusunoki M, Nakagawa K, et al. Evaluation of J-pouch
reconstruction after total gastrectomy: rho-double tract vs J-pouch
potential benefits, such as the need for one less entero- double tract. Dig Surg 2000; 17: 475–81.
entero anastamosis than with a duodenal passage 8 Horvath OP, Kalmar K, Cseke L, et al. Nutritional and life-quality
preserving procedure,10 the potential prevention of alkaline consequences of aboral pouch construction after total gastrectomy:
a randomized, controlled study. Eur J Surg Oncol 2001; 27: 558–63.
reflux oesophagitis,9 and the avoidance of potential 9 Schmitz R, Moser KH, Treckmann J. Quality of life after prograde
technical limitations associated with the formation of a jejunum interposition with and without pouch. a prospective study
duodenal passage.10,11 However, we recognise that our of stomach cancer patients on the reservoir as a reconstruction
principle after total gastrectomy. Chirurg 1994; 65: 326–32.
choice of procedure is not the conclusion of an objective 10 Fuchs KH, Thiede A, Engemann R, et al. Reconstruction of the food
clinical study but an assessment based on previous studies, passage after total gastrectomy: randomized trial. World J Surg
which have highlighted the potential advantage of this 1995; 19: 698–705.
11 Nakane Y, Okumura S, Akehira K, et al. Jejunal pouch
approach. reconstruction after total gastrectomy for cancer. a randomized
Each of the randomised prospective studies we have controlled trial. Ann Surg 1995; 222: 27–35.
included in this review used different endpoints and 12 Nakane Y, Michiura T, Inoue K, et al. A randomized clinical trial of
pouch reconstruction after total gastrectomy for cancer: which is
conceptually similar, but varied, operations. Furthermore, the better technique, Roux-en-Y or interposition?
there are conflicting conclusions regarding the benefit of Hepatogastroenterology 2001; 48: 903–07.
duodenal passage preservation and the usefulness of an 13 Troidl H, Kusche J, Vestweber KH, et al. Pouch versus
esophagojejunostomy after total gastrectomy: a randomized clinical
enteric reservoir. Overall the studies suggest a benefit for trial. World J Surg 1987; 11: 699–712.
reconstruction with pouch, and show little evidence to 14 Bozzetti F, Bonfanti G, Castellani R, et al. Comparing
warrant the additional technical demands of the reconstruction with Roux-en-Y to a pouch following total
gastrectomy. J Am Coll Surg 1996; 183: 243–48.
reconstruction of the duodenal passage. Further randomised 15 Liedman B, Andersson H, Berglund B, et al. Food intake after
and standardised studies are necessary to fully elucidate the gastrectomy for gastric carcinoma: the role of a gastric reservoir.
optimum approach in restoring intestinal continuity after Br J Surg 1996; 83: 1138–43.
16 Liedman B, Bosaeus I, Hugosson I, Lundell L. Long-term beneficial
total gastrectomy. effects of a gastric reservoir on weight control after total
Until the optimum method for reconstruction can be gastrectomy: a study of potential mechanisms. Br J Surg 1998; 85:
determined, investigators need to continue to systemically 542–47.
17 Iivonen MK, Koskinen MO, Ikonen TJ, et al. Emptying of the
define the appropriate quality of life indices and objective jejunal pouch and Roux-en-Y limb after total gastrectomy: a
parameters for comparisons of the various techniques randomised, prospective study. Eur J Surg 1999; 165: 742–47.
available for reconstruction after total gastrectomy. 18 Iivonen MK, Mattila JJ, Nordback IH, Matikainen MJ. Long-term
follow-up of patients with jejunal pouch reconstruction after total
Conflict of interest
gastrectomy. a randomized prospective study. Scand J Gastroenterol
2000; 35: 679–85.
None declared.
19 Gioffre Florio MA, Bartolotta M, et al. Simple versus double jejunal
pouch for reconstruction after total gastrectomy. Am J Surg 2000;
Acknowledgments 180: 24–28.
We would like to thank Lloyd M Nyhus for his help and guidance in the 20 Hunt C. Construction of food pouch from segment of jejunum as a
preparation of this manuscript and David Jho for his assistance with the substitute for stomach in total gastrectomy. Arch Surg 1952; 64:
figures. 601–08.
For personal use. Only reproduce with permission from The Lancet Publishing Group.