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Prof. G. de Manzoni
“Recenti acquisizioni fisiopatologiche post chirurgia
digestiva maggiore”STOMACO
Bari, November 8th
University of VeronaDepartment of SurgeryDivision of Upper G.I.
SurgeryProf. G. de Manzoni
Gastric Physiology
LESHis Angle
Pacemaker region
Pyloric sphincter
Allow: o bolous transito Mix of the bolous
Avoid:o acid refluxo biliary refluxo quick passage in
the duodenum
Gastric PhysiologyParietal
cells
Mucus cells
HCl production
Protection
Gastric Physiology
Vagus nerve
Celiac plexus
o Motility
o Secretions
Gastric Pathology
Peptic Ulcer
Cancer
Obesity
Main
VCancer of
gastric stump
Surgical goals
Resection Reconstruction
o Resection margins
(T0)
o Nodal dissection
(N0)
o Acid-Biliary reflux
o Good emptying
o Number of meals
o Body weight
o QOL
Surgical goalsThe
importance of QOL…
Cunningham D, et al. (2006) N Engl J Med
CT group: 36%
Surgery alone: 23%
5 y OS for advanced gastric
cancer
“cutting less does not always lead to better
results…”
Surgical goals
Gastric resections
Total Gastrectomy
JGCA (2011) Gastric Cancer
Distal Gastrectomy
JGCA (2011) Gastric Cancer
o Distal gastric tumors
o ≥ 3 or 5 cm proximal
margin (according to growth
pattern)
Gastric resections
Pylorus Preserving
JGCA (2011) Gastric Cancer
o Middle gastric tumors
o ≥ 4 cm from pylorus
Gastric resections
Proximal Gastrectomy
JGCA (2011) Gastric Cancer
o Proximal tumors
o ≥ ½ distal stomach preserved
Gastric resections
Gastric reconstructions
Total Gastrectomy
Roux-en-YLongmire
interposition
o Less biliary reflux 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
Body weight
No Differences QOL
Esophagitis
Mariette, et al.(2010) J Visc Surg
Gastric reconstructions
Total Gastrectomy
o Multicenter RCT (105 pz)
o Roux-en-Y VS Longmire
interposition
QOLNo Differences
Ishigami, et al.(2011) Am J Surg
Gastric reconstructionsPouch or
not?
Principles:
o Increase food intake at each
meal
o Prevent dumping syndrome
o Prevent reflux esophagitis (?)
Better QOL?
Gastric reconstructionsPouch or
not?
Dumping syndrome
o 9 RCT Roux-en-Y (474 pz)
Eating capability
Body weight
Long term better QOL…
Gertler, et al.(2009) Am J Gastroenterol
Pouch is better in…
Total Gastrectomy… In Japan
Kumagai, et al.(2012) Surg Today
o 145 Japanese institutions
o 138 use Roux-en-Y reconstruction
o 26 institutions performs Pouch
95% Roux-en-Y reconstruction
Gastric reconstructions
Mariette, et al. (2010) J Visc Surg
Distal Gastrectomy
Roux-en-YBillroth IBillroth II (+
Braun)
o Restore
physiologic path
o Always possible
without tension
o Less biliary reflux
Gastric reconstructions
Csendes, et al. (2009) Ann Surg
Distal Gastrectomy Roux-en-YBillroth II V
So 75 pz (mean fu 182-193 months)
o Surgery for peptic ulcer
Less reflux for Roux in long term follow-
up
Gastric reconstructions
Lee, et al. (2012) Surg Endosc
Distal Gastrectomy Roux-en-YBillroth II
+ BraunVS
o 159 pz (12 months fu)
o Prospective randomized trial
Endoscopic findings
Biliary reflux3.7% Roux vs
75% BII
Hepatobiliary scan
Gastric reconstructions
Distal Gastrectomy
Roux-en-YBillroth IBillroth II (+
Braun)
o High biliary
reflux
Gastric reconstructions
Inokuchi, et al. (2012) Gastric CancerSano, et al. (2007) Int J Clin Oncol
Distal Gastrectomy Roux-en-Y Billroth IV
S
Endoscopic findings
Gastric reconstructions
o Esophagitis
o Gastritis
o Food residue
o Bile reflux
P<0.05Better for Roux
Lee, et al. (2012) Surg Endosc
Distal Gastrectomy
Roux3.7%
Biliary Reflux
Roux-en-Y Billroth IVS
o 159 pz (12 months fu)
o Prospective randomized trial
Hepatobiliary scan
Billroth I56.3%
Gastric reconstructions
Takiguchi, et al. (2012) Gastric Cancer
Distal Gastrectomy Roux-en-Y Billroth IV
S
o 268 pz (21 months median fu)
o Multicenter randomized phase II
EORTC QLQ-C30
NO differencesin QOL
Gastric reconstructions
Distal Gastrectomy
Roux-en-YBillroth I
o High biliary
reflux
o High gastritit
o High
esophagitis
o High food
residue
NO differencesin QOL…
but
Gastric reconstructions
Roux-en-Y
o Less biliary
reflux
o Less gastritis
o Less esophagitis
o Less food
residue
o Roux stasis
syndrome
o Difficult
endoscopic
management of
bile ducts
Gastric reconstructions
Distal Gastrectomy… In Japan
Kumagai, et al.(2012) Surg Today
o 145 Japanese institutions
o 112 (77%) use B1 reconstruction as first
choice
o 30 (21%) use Roux reconstruction as first
choice
77% B1
21% Roux
Gastric reconstructions
Gastric reconstructions
Pylorus Preserving
Billroth I
Evolution
o Less dumping syndrome
o Less gastritis
o Less reflux esophagitis
o Less gallbladder stones
o More delayed gastric
emptying
o (Limited oncological
dissection)
Pros
Cons
Morita, et al.(2008) Br J Surg
Preservation of hepatich and pyloric branchs
Preservation of coeliach branch
Preservation of infrapyloric vessels
o 611 pz (50 months median fu)
Gastric reconstructions
Pylorus Preserving
o 39 pz (40 months mean fu)
o Pylorus preserving VS Billroth I
Park, et al.(2008) World J Surg
But…
Better Symptom score
Delayed Gastric
emptying for solids
Scintigraphic system
Gastric reconstructions
Proximal Gastrectomy
Pros Cons
Reflux esophagitis
Improved nutrition
Anastomotic stricture
Theoretically better for early stages proximal cancer and Siewert III
because of better QOL…
Gastric reconstructions
Proximal Gastrectomy
Kim, et al.(2012) Gastric Cancer
Laparoscopy assisted proximal gastrectomy VS total gastrectomy
o 131 pz
o Endoscopic evaluation for stenosis
o Modified Visick score for GERD
High Stenosis
High GERD
Gastric reconstructions
Proximal Gastrectomy
Kim, et al.(2012) Gastric Cancer
Same nutritional status
No advantages for PG instead of TG…
Gastric reconstructions
Our experience (2000-2010)
50 pz
Siewert II24 pz
Siewert III26 pz
o Short gastric conduit
reconstruction
o T-T mediastinal anastomosis
4 months30 pz
10 months15 pz
Reflux 9 (30%) 5 (33.3%)
Stenosis 6 (20%) 1 (6,7%)
Non pathologic 15 (50%) 9 (60%)
Our experience (2000-2010)
Endoscopic diagnosis
Cardias adenocarcinoma
Ivor Lewis
Siewert III
Total gastrecto
my
Proximal gastrecto
my
Siewert II Siewert I
Total gastrecto
my
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
4 months106 pz
10 months80 pz
Esophagitis 24 (22,6%) 20 (25%)
Stenosis 21 (19,8%) 3 (3,7%)
Non pathology
61 (57,6%) 57 (71,3%)
Our experience until 2010
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
Velanovich, et al.(2007) Dis Esophagus
QOL questionnaire
o Good reliability
o Good responsiveness
o Good praticality (2 minutes)
6 months 12 months
Esophagitis 5 (25%) 7 (35%)
Stenosis 3 (15%) 0 (0%)
Score > 10 6 (30%)
...2011 results
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
Prophylactic Cholecistectomy?
Rationale
o Higher risk of gallstones formation 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
hepatich branch of vagus nerve
Alteration in hormons production: cholecystokinin
and secretin
Altered motilityAltered motility
Altered secretions
Physiophatology
Cholelythiasis
In general
population 10%Symptomatic in 30%
15-25% develop cholelythiasis
…5 y after gastric surgery
Gillen, et al.(2010) World J Surg
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 cholecystectomyseems not to be necessary
Bernini, et al.(2012) Gastric Cancer
o RCT – end of recruitment analysis
o Propylactic cholecystectomy (PC) VS standard surgery (SS)
o Roux-en-Y and Billroth II
Perioperative complications
Biliary:PC 1.5% vs SS 0%
N.S.
Overall:PC 25% vs SS 17%
N.S.
1 pz: Bile from drainage: Conservative management (desappear in a few
days)
Giacopuzzi S, de Manzoni G…Cordiano C, et al.(2008) Biliary Lithiasis
Prophylactic cholecystectomy
Extended lymphadenecto
my (D2-D3)Total
Gastrectomy
Early stage (long survivor)
PC
Nothing is perfect… but everything can be
improved…
