University of Verona
Department of Surgery
Division of Upper G.I. Surgery
Prof. G. de Manzoni
“Recenti acquisizioni fisiopatologiche
post chirurgia digestiva maggiore”
STOMACO
Prof. G. de Manzoni
Bari, November 8th
Gastric Physiology
His Angle
Allow:
LES
o bolous transit
o Mix of the bolous
Pacemaker
region
Pyloric
sphincter
Avoid:
o acid reflux
o biliary reflux
o quick passage in the
duodenum
Gastric Physiology
Parietal
cells
Mucus cells
Gastric Physiology
Vagus
nerve
o Motility
o Secretions
Celiac plexus
Gastric Pathology
Main
Cancer
Peptic Ulcer
Obesity
Cancer of
gastric stump
Surgical goals
Resection
Reconstruction
o Resection margins (T0)
o Acid-Biliary reflux
o Nodal dissection
o Good emptying
(N0)
o Number of meals
o Body weight
o QOL
Surgical goals
The importance
of QOL…
Surgery
alone:
23%
5 y OS for advanced gastric cancer
CT group:
36%
Cunningham D, et al. (2006) N Engl J Med
Surgical goals
“cutting less does not always
lead to better results…”
Gastric resections
Total Gastrectomy
JGCA (2011) Gastric Cancer
Gastric resections
Distal Gastrectomy
o Distal gastric tumors
o ≥ 3 or 5 cm proximal margin
(according to growth pattern)
JGCA (2011) Gastric Cancer
Gastric resections
Pylorus Preserving
o Middle gastric tumors
o ≥ 4 cm from pylorus
JGCA (2011) Gastric Cancer
Gastric resections
Proximal
Gastrectomy
o Proximal tumors
o ≥ ½ distal stomach preserved
JGCA (2011) Gastric Cancer
Gastric reconstructions
Total
Gastrectomy
Roux-en-Y
o Less biliary reflux
Longmire
interposition
o Preservation of physiological
route
o Improved absorption
o Reduced weight loss
Gastric reconstructions
Total
Gastrectomy
o Review of 9 RCT (1985-2009)
o Roux-en-Y VS Longmire interposition
No Differences
Esophagitis
Body weight
QOL
Mariette, et al.(2010) J Visc Surg
Gastric reconstructions
Total
Gastrectomy
o Multicenter RCT (105 pz)
o Roux-en-Y VS Longmire interposition
QOL
No Differences
Ishigami, et al.(2011) Am J Surg
Gastric reconstructions
Pouch or not?
Principles:
o Increase food intake at each meal
o Prevent dumping syndrome
o Prevent reflux esophagitis (?)
Better QOL?
Gastric reconstructions
Pouch or not?
o 9 RCT Roux-en-Y (474 pz)
Pouch is better in…
Body weight
Eating capability Long term better
QOL…
Dumping
syndrome
Gertler, et al.(2009) Am J Gastroenterol
Gastric reconstructions
Total
Gastrectomy…
In Japan
95% Roux-en-Y reconstruction
o 145 Japanese institutions
o 138 use Roux-en-Y reconstruction
o 26 institutions performs Pouch
Kumagai, et al.(2012) Surg Today
Gastric reconstructions
Distal
Gastrectomy
Billroth I
o Restore
physiologic path
Billroth II (+
Braun)
o Always possible
Roux-en-Y
o Less biliary reflux
without tension
Mariette, et al. (2010) J Visc Surg
Gastric reconstructions
Distal
Gastrectomy
o
75 pz (mean fu 182-193 months)
o
Surgery for peptic ulcer
Billroth II
VS
Roux-en-Y
Less reflux for Roux in
long term follow-up
Csendes, et al. (2009) Ann Surg
Gastric reconstructions
Distal
Gastrectomy
o
159 pz (12 months fu)
o
Prospective randomized trial
Endoscopic findings
Billroth II
+ Braun
VS
Roux-en-Y
Hepatobiliary scan
Biliary reflux
3.7% Roux vs
75% BII
Lee, et al. (2012) Surg Endosc
Gastric reconstructions
Distal
Gastrectomy
Billroth I
Billroth II (+
Braun)
o High biliary reflux
Roux-en-Y
Gastric reconstructions
Distal
Gastrectomy
o Esophagitis
o Gastritis
Roux-en-Y
VS
Billroth I
Better
for
Roux
P<0.05
o Food residue
o Bile reflux
Endoscopic findings
Inokuchi, et al. (2012) Gastric Cancer
Sano, et al. (2007) Int J Clin Oncol
Gastric reconstructions
Distal
Gastrectomy
o
159 pz (12 months fu)
o
Prospective randomized trial
Roux-en-Y
VS
Billroth I
Biliary Reflux
Roux
3.7%
Hepatobiliary scan
Billroth I
56.3%
Lee, et al. (2012) Surg Endosc
Gastric reconstructions
Distal
Gastrectomy
o
268 pz (21 months median fu)
o
Multicenter randomized phase II
EORTC QLQ-C30
Roux-en-Y
VS
Billroth I
NO differences
in QOL
Takiguchi, et al. (2012) Gastric Cancer
Gastric reconstructions
Distal
Gastrectomy
Billroth I
o High biliary reflux
o High gastritit
o High esophagitis
o High food residue
but
NO differences
in QOL…
Roux-en-Y
Gastric reconstructions
Roux-en-Y
o Less biliary reflux
o Roux stasis syndrome
o Less gastritis
o Difficult endoscopic
o Less esophagitis
management of bile
o Less food residue
ducts
Gastric reconstructions
Distal
Gastrectomy…
In Japan
77% B1
21% Roux
o
145 Japanese institutions
o
112 (77%) use B1 reconstruction as first choice
o
30 (21%) use Roux reconstruction as first choice
Kumagai, et al.(2012) Surg Today
Gastric reconstructions
Pylorus
Preserving
Billroth I
Pros
o
Less dumping syndrome
o
Less gastritis
o
Less reflux esophagitis
o
Less gallbladder stones
Cons
o
More delayed gastric emptying
o
(Limited oncological dissection)
Gastric reconstructions
Preservation of hepatich
and pyloric branchs
Preservation of coeliach
branch
Preservation of infrapyloric
vessels
o
611 pz (50 months median fu)
Morita, et al.(2008) Br J Surg
Gastric reconstructions
Pylorus
Preserving
o
39 pz (40 months mean fu)
o
Pylorus preserving VS Billroth I
Better Symptom score
But…
Delayed Gastric
emptying for
solids
Scintigraphic system
Park, et al.(2008) World J Surg
Gastric reconstructions
Proximal
Gastrectomy
Pros
Cons
Theoretically better for
Reflux esophagitis
early stages proximal
Improved cancer
nutrition and Siewert III
because of better QOL…
Anastomotic
stricture
Gastric reconstructions
Proximal
Gastrectomy
o
131 pz
o
Endoscopic evaluation for stenosis
o
Modified Visick score for GERD
Laparoscopy assisted proximal gastrectomy VS total gastrectomy
High Stenosis
High GERD
Kim, et al.(2012) Gastric Cancer
Gastric reconstructions
Proximal
Gastrectomy
Same nutritional
status
No advantages for PG
instead of TG…
Kim, et al.(2012) Gastric Cancer
Our experience (2000-2010)
50 pz
Siewert II
24 pz
Siewert III
26 pz
o
Short gastric conduit reconstruction
o
T-T mediastinal anastomosis
Our experience (2000-2010)
4 months
30 pz
10 months
15 pz
Reflux
9 (30%)
5 (33.3%)
Stenosis
6 (20%)
1 (6,7%)
Non pathologic
15 (50%)
9 (60%)
Endoscopic diagnosis
Cardias adenocarcinoma
Siewert III
Siewert II
Siewert I
Total
gastrectomy
Total
gastrectomy
Ivor Lewis
Proximal
gastrectomy
Ivor Lewis
Ivor Lewis – Personal Tecnique
o Narrow gastric conduit
o Intramediastinical conduit position
o GERD reduction
Termino-Terminal
Anastomosis
o Better vascularization
o Avoids the “could de sac”
o Without weaknesses
Prefer intrathoracic
anastomosis
o Eases the venous outflow
o Less tension on the anastomosis
o Over-azygos for GERD reduction
o Shorter conduit with better vascularization
Our experience until 2010
4 months
106 pz
10 months
80 pz
Esophagitis
24 (22,6%)
20 (25%)
Stenosis
21 (19,8%)
3 (3,7%)
Non
pathology
61 (57,6%)
57 (71,3%)
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
QOL questionnaire
o Good reliability
o Good responsiveness
o Good praticality (2 minutes)
Velanovich, et al.(2007) Dis Esophagus
...2011 results
6 months
12 months
Esophagitis
5 (25%)
7 (35%)
Stenosis
3 (15%)
0 (0%)
Score > 10
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
6 (30%)
Prophylactic Cholecistectomy?
Rationale
o Higher risk of gallstones formation
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Vagal denervation
Postoperative fasting
Extent of lymphadenectomy
Extent of gastric resection
Digestive reconstruction
o Difficult endoscopic management (Roux-en-Y)
o Higher morbi-mortality for subsequent cholecistectomy
Physiophatology
Alteration in hormons
production: cholecystokinin and
secretin
Altered motility
Altered secretions
hepatich branch of vagus
nerve
Altered motility
Cholelythiasis
In general
Symptomatic in
population 10%
…5 y after gastric
surgery
15-25% develop
cholelythiasis
30%
o
16 studies (retrospective and prospective)
o
3735 pz
CCE: cholecistectomy
High morbidity in
delayed CCE
Low additional
morbidity for the
whole cohort
Gillen, et al.(2010) World J Surg
o
16 studies (retrospective and prospective)
o
3735 pz
Simultaneous cholecystectomy
seems not to be necessary
Gillen, et al.(2010) World J Surg
o
RCT – end of recruitment analysis
o
Propylactic cholecystectomy (PC) VS standard surgery (SS)
o
Roux-en-Y and Billroth II
Perioperative complications
Overall:
PC 25% vs SS 17%
N.S.
Biliary:
PC 1.5% vs SS 0%
N.S.
1 pz: Bile from drainage: Conservative
management (desappear in a few days)
Bernini, et al.(2012) Gastric Cancer
Prophylactic cholecystectomy
Extended
lymphadenectomy
(D2-D3)
Total Gastrectomy
PC
Early stage (long
survivor)
Giacopuzzi S, de Manzoni G…Cordiano C, et al.(2008) Biliary Lithiasis
Nothing is perfect…
but everything can be improved…