Different methods of alimentary tract reconstruction after gastrectomy

ZHOU Jie，FAN Yuezu

Tongji University School of Medicine，Shanghai 200092，China

·综 述·

Different methods of alimentary tract reconstruction after gastrectomy

ZHOU Jie，FAN Yuezu

Tongji University School of Medicine，Shanghai 200092，China

Stomach cancer is one of the most common malignant neoplasms.After gastrectomy for gastric cancer，the integrity of the alimentary tract was destroyed，influencing the functions of stomach such as storage，mixture of food，initial digestion and absorption of many substances，which finally leads to malnutrition and poor quality of life. Therefore，the selection of the methods of reconstruction is particularly significant.The best reconstruction method is one that keeps patients maintain satisfactory nutritional status and quality of life and keeps postoperative morbidity as low as possible.This review focuses on the different methods of alimentary tract reconstruction after radical gastrectomy.

Gastrectomy；Alimentary tract reconstruction；Open resection

1 Introduction

Stomach cancer is one of the most common malignant neoplasm diseases，which is still a poor prognosis and high mortality disease.Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide，the absolute number of new cases per year is increasing because of the aging of the population.So far，surgical resection with curative intent has been the only treatment providing hope for cure[1].But，the excision of the stomach leads towards several digestive tract functioning disturbances.The following functions of the stomach are influenced：storage，mixture of food，initialdigestion and absorption of many substances.The excision of natural sphincters（pylorus and cardia）leads towards fast passage of food to the small bowel，and reflux of the alkaline contents to the esophagus.Moreover，in case of duodenal closure，the secretion of intestinal peptides is impaired，and absorption of fat，iron，calcium and other elements is reduced.Therefore，the reconstruction of alimentary tract is of great significance.

It has been generally accepted that the optimum procedure of alimentary reconstruction after total gastrectomy must fulfill the following requirements：（1）maintain the fluency of duodenal food passage.（2）a good digestive and absorptive function of the gastric substitute.（3）minimal or no“non-gastric syndromes”（e.g.，reflux esophagitis，dumping syndrome，lack of appetite，feeling of gull and being bloated，and indigestion）.（4）keeps the patients in good postoperative nutritional status and have betterquality of life，and（5） safe，simple，and less postoperative complications and mortality.However，no reconstruction procedures have been reported to meet all the above requirements[2].

Surgical resections of gastric cancer consist of total gastrectomy，proximal gastrectomy and distal gastrectomy.The methods of postoperative reconstruction of alimentary tract are different according to the methods of gastrectomy and patient’s physical state.All the undermentioned surgical margins should be confirmed to be negative for cancer cells by frozen-section examination of resected specimens.

2 Reconstructions after total gastrectomy of gastric cancer

One of the important issues for clinical application of total gastrectomy is the technique of reconstruction after resecting the stomach.More than 50 reconstruction procedures have been reported[3]. There are several feasible and common procedures.

2.1 Roux-en-Y esophagal jejunal anastomosis

Orr Roux-en-Y esophagal jejunal anastomosis（RY）

After total gastrectomy，with the duodenum stump sutured，an isoperistaltic jejunal limb，15-20 cm from the angle of Treitz，is brought up and anastomosed end-to-side to the distal esophagus.This limb can be brought up through the mesocolon（transmesocolic or retrocolic）or in front of the transverse colon（precolic），and the latter prevents early involvement in case of local recurrence.The distal end is anastomosed end-to-side to the first jejunal loop，allowing the biliopancreatic secretions to regain the intestinaltract.The loop used for esojejunal anastomosis must be sufficiently long，mobile and well vascularized to reach the distal esophagus in front of the transverse colon without tension[4].The Orr Roux-en-Y reconstruction is the simplest surgical solution after total gastrectomy. There is approximate 50 cm jejunum loop between the esojejunal anastomosis and the jejunal end-to-side anastomosis，preventing the alkaline intestinal contents（bile and duodenal juice）from refluxing to the esophagus，thus effectively reduces the morbidity of reflux esophagitis.For patients those who don’t have enough length of jejunum for creating a jejunal reservoir，itisone ofthe mostclassicaland recommendable alimentary reconstruction methods. Use ofthe Roux-en-Y reconstruction hasbeen gradually increasing in recent years，most likely to avoid anastomotic leakage and reflux inflammation of the remnant stomach[5].However，the disadvantages of RY include the possible development of stomach ulcers，an increased probability of cholelithiasis[6]，increased difficulty with an endoscopic approach to the papilla of Vater，and that all food passes though the jejunum，bypassing the duodenum and entering the small intestine largely undigested，leading to poor absorption of medium chain triglycerides and dumping syndrome.The disruption of intestinal integrity and enteric neural continuity leads to the subsequent disorder ofintestinalmotility，which is called Roux-en-Y syndrome （RSS）[3]. Roux-en-Y reconstruction creates several intraabdominal spaces that can promote internal herniation[5].The most frequent sites of internal hernias were jejunojejunostomy mesenteric defects and Petersen’s defect，mesenterium of transverse colon，and esophagus hiatus.Closure of the mesenteric defects（jejunojejunal defect and Petersen’s space）at the time of initial operation is recommended after an antecolic Roux-en-Y reconstruction to minimize the incidence of internalhernia[7].

（2）Double tract Roux-en-Y esophagal jejunal anastomosis（DTR）

The DTR method differs from the Orr Roux-en-Y method by the fact that the duodenum is anastomosed to the jejunum 35 cm far from the esophagojejunal anastomosis. Because of the duodenojejunal anastomosis，part of the chyme passes through the duodenum and adequately stimulates secretion of bile and pancreatic juice.In case of intact duodenalpassage，the digestive and absorption functions of the duodenum are maintained，resulting in a considerably more rapid absorption of medium chain triglycerides at a rate that is almost the same as that seen in healthy controls.Partial food passagethrough the duodenum has the positive impact on the motility of the distal alimentary tract，digestive function，absorption of lipids，and gastrointestinal hormones[6].So，the patient’s postoperative complications are significantly reduced with better quality of life and longer survival.The remaining nutritional passage is similar to that observed in case of the Orr Roux-en-Y method[8].The time duration of the procedure and percentage of complications is similar to that observed in case of the Orr Roux-en-Y method. Theoretically， due to the additional duodenojejunal anastomosis，the possibility of postoperative leakage is increased，but investigations did not confirm it.The problem of the impaired storage function was solved by the creation of an additional intestinal pouch，partly compensating for the lack of the stomach.Although the duodenojejunostomy which facilitates the reflux of bile and pancreatic juice into the stomach may causes subsequent reflux into the esophagus，the incidence of remnant gastritis and reflux esophagitis was not increased in the patient undergoing DT reconstruction[6].Anotheradvantage is thateasy endoscopic access to the papilla of Vater can be achieved in patients with DT reconstruction after gastrectomy for gastric cancer.Furthermore，if biliary disorders develop after gastrectomy，therapeutic ERCP can be performed in these patients without serious complications，avoiding the need for invasive treatments，including a surgical approach[9].

（3）Pouch-double tract Roux-en-Y esophagal jejunal anastomosis（PDT）

After TG，retrocolic esophagojejunostomy is performed.End-to-side duodenojejunal anastomosis isperformed on a13-cm segmentofelevated jejunum.A 5-cm jejunal pouch is prepared using the seromuscular suture method at duodenojejunal anastomosis site.The PDT reconstruction method after TG has the benefits not only from an interposed pouch but also from a double tract.Patients who were reconstructed with PDT after TG showed better nutritional conditions than patients who were reconstructed with traditional RY[10].This PDT method reduces the possibility of dumping syndrome.

（4）P-shape Roux-en-Y esophagojejunal anastomosis

The procedure of P-shape Roux-en-Y esophagojejunal anastomosis is similar to the Orr Roux-en-Y method exceptthatthe isoperistaltic jejunal limb is folded to create a“P”type jejunal loop，the midportion of the“P”is opened and the two limbs are anastomosed together.The top of“P”type jejunal loop is anastomosed end-to-side to the distal esophagus.Apart from containing the advantage of anti-reflux function as the classicalRoux-en-Y method has，the P-type reservoir theoretically recreates the storage function of the stomach and therefore improves the patient’s eating capacity，maintains body weight，and preserves quality of life.However，as the jejunum was cut off and intestinal integrity and enteric neural continuity was destroyed，leading to the subsequent disorder of intestinal motility and syndromes of abdominal pain，nausea，vomiting and fullness，the probability of postoperative complication is increased.

2.2 Jejunum interposition on behalf of stomach surgery

（1）Jejunum interposition（JI）

After total gastrectomy，a segment of jejunum with strong feeding artery is divided at the level of the first loop at a point 30 cm distal from the ligament of Treitz.The isolated segment is passed through transverse mesocolon and anastomosed end-to-end to the esophagus and to the duodenum respectively. Intestinal continuity is established by jejunostomy. This method preserves the duodenum passage，which capacitates initially digested chyme adequately stimulates the secretion of bile and pancreatic juice. However，the capacity deficiency of the interpositional jejunum will result in rapid passage of the chyme through the intestinal tract，which leads to postoperative complications such as dumping syndrome and impaired quality of life.

（2）Functional jejunum interposition（FJI）

After total gastrectomy，firstly，a segment of jejunum about 30 cm long at a point 30 cm distal fromthe ligament of Treitz is divided and is passed through transverse mesocolon and brought up to be anastomosed with the esophagus.Secondly，an end-to-side duodenojejunostomy is created at the efferent limb 35 cm distal to the esophagojejunostomy，followed by a side-to-side jejunostomy at 5 cm distal to duodenojejunostomy and 20 cm distal to Treitz’s ligament. Finally，2 jejunal proper ligations are made at 5 cm oral to esophagojejunostomy and 2 cm distal to duodenojejunostomy.The ligation has medium tension that it is tight enough to stop the food transit，yet not tight enough to lead to regional jejunal necrosis.Because the jejunum is ligated rather than transected，there would be fewer jejunal stumps and anastomoses compared to reconstruction with jejunal transection. The technique of jejunal functional ligation used for FJI has been found to exert both the benefits of preserving jejunal integrity and maintaining duodenal food passage，and the postoperative complications such as reflux esophagitis，dumping syndrome，nausea and vomiting are significantly decreased[3].In addition，by changing the operation procedure with proper jejunum ligation，FJI is less time-consuming and less costly.So the FJI is a highly recommended alimentary reconstructionmethodaftertotalgastrectomy.

（3）Modified jejunum interposition（mJI）

After total gastrectomy，a side-to-side jejunostomy was created at the two points 15 cm distal and 65 cm distal from the Treitz’s ligament to create a jejunum loop of 50 cm long.Put a 20 cm segment of the jejunum loop between the esophagus and the duodenum and then make end-to-side anastomoses to them respectively.Thismethod reconstructsthe alimentary tract without cutting of the jejunum and preserves jejunal integrity，reducing the morbidity of postoperative complication aforementioned. The proximal jejunum of the loop has great intestinal absorption functions，which decreases the rate of malnutrition and severe weight loss.

（4）Jejunal pouch interposition with a fundiclike jejunal plication（JPI-FP）

2.3 Moynihan anastomosis（Braun anastomosis）

After total gastrectomy，with the distal end of the duodenum sutured，an end-to-side esophagojejunostomy is made at 40-45 cm distal to the Treitz’s ligament，and then a 10 cm side-to-side jejunostomy is made between the afferent jejunal loop and the transposed jejunal loop，which is also called Braun anastomosis.The original purpose of Moynihan-type procedure isto reduce the incidence ofreflux esophagitis by means of Braun anastomosis. However，in fact，the side-to-side jejunostomy between the afferent and transposed jejunal loop fails to transfer bile and pancreatic secretions.As the lower esophageal sphincter is resected at total gastrectomy，the synperistaltic function of the afferent jejunal loop can transport the alkaline digestive juice to the distal part of the esophagus in Moynihan-type reconstruction.Sometimes，the food chyme or alkaline digestive juice can circulate through the Braun anastomosis，thuscausing lesionsto the esophagus mucosa[2].This method is appropriate for patients with advanced stomach cancer and poorhealth state.

3 Reconstructions after proximal gastric resection of gastric cancer

3.1 Esophagogastrostomy（EG）

It is also called inverted-Billroth I anastomosis. The lesser curvature of remnant stomach is sutured，and the greatercurvature is anastomosed with esophagus.The anastomosis is performed at the site of the anterior wall，which is 2-3 cm from the lesser curvature and 2-3 cm from the top of the remnant of the stomach[11].EG has advantages over JI and JPI such as shorter operative time，lesser intraoperative blood loss，decreased morbidity rate，and lesser postoperative body weight loss.This method is simple to perform buteasily leads to reflux esophagitis because of the resection of lower esophageal sphincter.The ulceration usually occurs at the anastomosis of esophagus and the greater curvature，to which attention should be paid in postoperative follow-up.

3.2 Jejunum interposition（JI）

A 10-15 cm jejunum limb is brought up via the retrocolic route，and is anastomosed end-to-side with the esophagus and end-to-side with the remaining stomach.JI and JPI have advantages of preventing reflux esophagitis.However，patients undergoing JI or JPI are more likely to develop intestinal obstruction[11].For patients with gastric cancer on the upper third of stomach，Jejunum interposition after proximal gastrectomy（PG）is preferred over total gastrectomy（TG） in terms of prevention of postoperative anemia. However，periodic upper endoscopic follow-up is necessary to monitor the uppergastrointestinaltractbecause PG showed comparable oncological radicality to TG.Jejunum interposition after PG is not recommended at a hospital that cannot perform the surveillance endoscopy，otherwise the remnant stomach may cause critical comorbidity in PG patients[12].

3.3 Jejunum pouch interposition（JPI）

在灌注桩浇筑完混凝土28 d后进行桩基检测，其中对3根采用支盘工艺的单桩承载力做了全数检测，其高应变检测数据见表1。

To construct a 10-15 cm reverse U-shaped jejunal pouch，a 25-35 cm jejunum limb is brought up via the retrocolic route and anastomosed end-to-side with the esophagus and end-to-side with the remaining stomach.For patients with gastric cancer in the upper third of the stomach，JPI after proximal gastrectomy results in better physical functioning，and less dyspnea，insomnia，and diarrhea on short term outcomes compared with RY reconstruction after total gastrectomy.Moreover，patients undergoing JPI after proximal gastrectomy had the significant advantage of increased food intake.Furthermore，JPI enables the detection of gastric stump carcinomas after proximal gastrectomy because it facilitates easier postoperative endoscopic examination.However，there was no significant difference in the change in body weight between JPI group and RY group.The positive impact ofJPIon long-term outcomes was decreased compared with short-term outcomes[13].

3.4 Esophagogastrostomy with fundoplication

For esophagogastrostomy with fundoplication，the esophagus is dissected circumferentially，exposing both right and left crura of the diaphragm. The esophagealhiatusiswidened，sucuring an adequate space to accommodate the remnant stomach. Proximal gastrectomy is performed extracorporeally. After making a small hole in the anterior wall of the stomach，the gastric remnant is returned to the abdomen，and esophagogastrectomy is performed. Then，the greater curvature side of the gastric remnant is sutured to the anterior wall of the esophagus with two stitches，and the lesser curvature side is sutured to the right side of the esophagus with two stitches. The gastric remnantis wrapped around about two-thirds of the circumference of the esophagus. Finally，the gastric wall is sutured to the left and right crura of the diaphragm with one stitch each to prevent the anastomosis from sliding into the mediastinum. Esophagogastrostomy is the simplest procedure for reconstruction after proximal gastrectomy，but it has a high postoperative risk for reflux esophagitis.The fundoplication prevents gastric content from refluxing to esophagus and is associated with a low incidence of postoperative syndromes such as heartburn and swallowing discomfort，and what more important is that this procedure is simple to perform.This procedureshould be done for the patients with remnant stomach largeenoughtomakeafundoplication[14].

3.5 Esophagogastrostomy plus gastrojejunostomy reconstruction(EGY)

The esophagus is separated and cut off and the anterior wall of the stomach is slit.Precolonic gastrojejunostomy is completed using the circular stapler between the greater curvature of the lower body of the posterior stomach wall and the jejunum.The gastrojejunostomy anastomosis is about 15-20 cm apart from the Treitz ligament.An end-to-side direct anastomosis is performed between the esophagus and the greater curvature of the upper body of the posterior stomach wall.Although an additional operative step，gastrojejunostomy，is required when compared with esophagogastrostomy（EG），the operation time and intraoperative bleeding volume were not significantly increased.What may be the most obvious advantage of EGJ is that，compared with RY，the physiological functions of the gastric remnant are preserved by EGJ and more food intake is possible.In addition，the remnant stomach can partly retain gastrointestinal hormone production.Several points should be taken into account when performing EGJ procedure.First，gastrojejunostomy should be conducted ahead of esophagogastrostomy in order to avoid pulling the esophagogastric anastomosis.Second，the jejunum should be about 15-20 cm apart from the Treitz ligament to be suitable for gastrojejunostomy，and the anastomosis should be a little largerthan the esophagogastric anastomosis for gastric emptying. Lastly，under the premise of a negative resection margin，increased distance between esophagogastrostomy and gastrojejunostomy anastomosis will be a better approach to avoid affecting the blood supply betweenthetwoanastomoses[15].

4 Reconstructions after distal gastric resection of gastric cancer

4.1 Billroth I anastomosis

The gastroduodenal anastomosis is performed end-to-end between the duodenum and the distal end of gastric remnant.The advantage of this procedure is to restore a physiologicaldigestive circuitand preserve the duodenal food passage.However，when leakage occurs，the site of the anastomosis prohibits continuation ofenteralnutrition.Itisofgreat importance that the duodenal stump be healthy，well vascularized and that the anastomosis be performed without undue tension[8].

4.2 Billroth II anastomosis

After distal gastrectomy，the duodenal stump is sutured，and Billroth II anastomosis is performed side-to-side between the gastric remnantand a proximal jejunal loop. Contrary to Billroth I reconstruction，Billroth II gastrojejunostomy is always possible without undue tension.This method is simple to perform，but it leads to much more severe bile reflux and gastritis than both Billroth I anastomosis and Roux-en-Y anastomosis.

4.3 Roux-en-Y anastomosis of remnant stomach and jejunal

After distal gastrectomy，the duodenum stump is sutured，an isoperistaltic jejunal limb，15-20 cm from the angle of Treitz，is brought up and anastomosed end-to-side to the remnant stomach.The distal end is anastomosed end-to-side to the first jejunal loop，allowing the biliopancreatic secretions to regain the intestinal tract.After distal gastrectomy，Roux-en-Y construction seems superior to Billroth I and Billroth II constructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors[4]. The afferentloop obstruction isan uncommon complication of distal gastrectomy with Roux-en-Y reconstruction.Afferent loop obstruction may be due to internal herniation， adhesions， kinking， a gastrointestinal stone， or stenosis caused by inflammatory changes or malignancy.The clinical diagnosis of afferent loop obstruction can be difficult because the symptoms are nonspecific.When a patient develops abdominal pain and vomiting after distal gastrectomy with Roux-en-Y reconstruction，this rare but potentially fatal disease should be borne in mind，and abdominal CT should be planned[16].

4.4 Jejunum interposition(JI)

After distal gastrectomy，a 10-12 cm jejunum，which is prepared at a point 20-30 cm distal from the ligament of Treitz，was brought through the transverse mesocolon，and was anastomosed in an isoperistaltic orientation to the greater curvature of the stomach and duodenum.Both gastrojejunal and jejunoduodenal anastomoses were performed end to end.Patients undergoing JI had low rates of weight loss，dumping syndrome，diarrhea，and reflux gastritis and esophagitis.However，itis a complicated procedure with three anastomoses and consumes more time than other reconstruction procedures.So it should only be indicated for those patients without severe general health problems and history of other disease.Additionally，the potential occurrence of the anastomotic ulcer at the site of the gastrojejunostomy should be aware of in the postoperative follow-up[17].

4.5 Pylorus-preserving gastrectomy(PPG)

Pylorus-preserving gastrectomy（PPG），with limited stomach resection and lymph node dissection，is an example of function-preserving surgery that can improve late-postoperative phase function[18]. In general，PPG is performed in patients who are preoperatively diagnosed with cT1N0M0primary GC in the middle third of the stomach when the distal border of the tumor is approximately 4-5 cm away from the pylorus.The infrapyloric and right gastric veins should be preserved to maintain blood flow in order to prevent postoperative edema of the pyloric cuff.Complete dissection of both veins could induce severe edema ofthe pyloric cuff，resulting in long-term postoperative retention of food in the residual stomach[19].The advantage of PPG is the prevention of postgastrectomy symptoms such as dumping syndrome and bile reflux gastritis，as well as reduced frequency of flatus.Moreover，the reservoir function of the remnant stomach may promote better body weight（BW）recovery after PPG than after DG with Billroth I reconstruction[18]. For patients undergoing PPG， the nutritional status and hemoglobin levels are better than those undergoing distal gastrectomy（DG），and the progressive body weight loss is less severe than that in DG.Moreover， PPG shows immunological benefit because that the number of peripheral lymphocyte recovered within 1 month and continuously increased during a period of 2 years after surgery[25].However，delayed-gastric emptying after PPG resulting in patient-reported gastric fullness is a disadvantage of PPG[19].The residual food in the remnant stomach may cause esophagitis or gastritis in PPG patients.So it’s not appropriate in elderly patients and those with hiatus hernia or esophagitis.Preservation of the celiac branch of the vagal nerve at gastrectomy improved postoperative gastrointestinalmovementincluding that in the residual stomach[20].

5 Conclusion

In conclusion，Orr-type Roux-en-Y esophagojejunostomy is safe and technically less demanding and can contribute to the avoidance of reflux esophagitis effectively，therefore，Orr-type Roux-en-Y reconstruction can be recommended asan adoptable method of digestive reconstruction after total gastrectomy for gastric cancer[2，21].However，there is not yet a unified standard method for the alimentary tract reconstruction after subtotal gastrectomy.The type of reconstruction must be discussed case-by-case，abiding by the principle ofsafe，effective，convenient and quality of life guaranteed，the experience of the surgical team managing the patients should be taken into account.

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胃癌切除术后消化道重建方式

周 捷（综述），范跃祖（审校）
同济大学医学院，上海 200092

胃癌是最常见的恶性肿瘤之一。胃切除术后，消化道的完整性遭到了破坏，胃的贮存食物、混合食物、初步消化和吸收功能受到影响，可导致患者营养不良和生活质量下降。因此，消化道重建方式的选择尤为重要。胃癌根治术后消化道重建方式种类繁多，操作简便、保证患者术后良好的营养状态、生活质量并减少并发症是最佳的重建方式。本文对胃癌根治手术后常用的消化道重建方式做一综述。

胃切除术；消化道重建；开腹手术

R656.6

A

2095-378X（2015）04-0270-08

周 捷（1994—），女，浙江金华人，同济大学医学院在读本科生

范跃祖，电子信箱：fanyuezu@hotmail.com

10.3969/j.issn.2095-378X.2015.04.017