Evaluation of postoperative quality of life by PGSAS-45 following local gastrectomy based on the sentinel lymph node concept in early gastric cancer.

BACKGROUND: The usefulness of sentinel node navigation surgery (SNNS) for early gastric cancer has been demonstrated in a multicenter prospective study. However, quality of life (QOL) after local resection remains unclear. This present study investigated QOL after local resection and distal gastrectomy. METHODS: We examined 69 patients who underwent laparoscopic distal gastrectomy (LADG) (n = 44) and laparoscopic local resection (LLR) (n = 25) in our hospital between September 2011 and May 2018. We conducted a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET) with SNNS as LLR. All patients had pStage I or II and none had received adjuvant chemotherapy. We evaluated QOL using the postgastrectomy syndrome assessment scale questionnaire (PGSAS-45) 1, 6, and 12 months after surgery. RESULTS: In PGSAS-45, no significant differences were observed between LLR and LADG at 1 and 6 months after surgery. At 12 months, the LLR group scored better for some of the subscales (SS). In the endoscopic evaluation, the LLR group showed significant improvements in residual gastritis at 6 months (P = 0.006) and esophageal reflux and residual gastritis at 12 months (P = 0.021 and P = 0.017). A significant difference was observed in the prognostic nutritional index, which was assessed using serum samples, between the two groups at 6 months (P = 0.028). The body weight ratio was better in the LLR group than in the LADG group at 6 and 12 months (P = 0.041 and P = 0.007, respectively). CONCLUSIONS: CLEAN-NET with SNNS preserved a better QOL and nutrition status than LADG in patients with early gastric cancer.

[RESULTS OF GASTROPLASTY, USING ILEOCECAL SEGMENT OF INTESTINE AFTER COMBINED GASTRECTOMY].

Results of treatment of 18 patients for locally spread gastric cancer, in whom after combined gastrectomy gastroplasty was accomplished, using ileocecal intestinal segment (the main group), were presented. In a comparison group 20 patients were included, in whom after combined gastrectomy end-to-loop esophagojejunoanastomosis was formated. Early postoperative complications have occurred in the main group--in 7 (38.8%) patients, and in comparison group--in 6 (30%). Postoperatively 2 (11.1%) and 2 (10%) patients died, accordingly. Gastroplasty, using ileo-cecal intestinal segment, have promoted reduction of the remote postgastrectomy syndromes occurrence rate from 58.8 to 11.1%. In a comparison group median survival was 18.6 mo, and in the main--a survival mediana was not achieved, because the investigation still goes on.

[Nutritional status in patients after gastrectomy due to gastric cancer].

UNLABELLED: Aim of the study was to evaluate nutritional status in patients after gastrectomy due to gastric cancer. METHODS: In 55 (26 males and 29 females) gastric cancer patients after gastrectomy body composition (bioimpedansometry method); resting energy expenditures and home actual nutrition (frequency analysis method) were evaluated. Blood levels of major nutrients and metabolites were assessed. RESULTS: Both men and women suffered from weight loss after gastrectomy (mean BMI was 19,8+/-4,7 kg/m2 in men and 20,5+/-1,9 in women). Higher BMI was positively correlated with age in women (R=0,45; p<0,03), but not in men, however there was no difference in mean age and mean time after gastrectomy between men and women. Mean body fat mass significantly decreased in men (7,4+/-5,0 kg) and in women (12,0+/-7,1 kg) in compare to normal values (18,2 and 22,5 correspondingly) (p<0,001). Resting energy expenditure variably decreased (for 13-53%) in half of the patients, mainly due to decrease in lipid oxidation rate. Mean daily energy intake was lower than normal in short-term (1359 kcal in period of 12 months) and long-term (1814 kcal in 1-5 years period) after gastrectomy, due to decrease consumption of proteins, carbohydrates and fat. Mean blood total protein, hemoglobin and hematocrit levels were lower than normal values in 40% of patients. CONCLUSION: In gastric cancer patients low BMI, low fat mass and energy consumption are observed even long period of time after gastrectomy. Dietary counseling and support are badly needed in patients short-term as well as long-term period after gastrectomy in men and younger women.

Total gastrectomy causes a sustained, long-term elevation of somatostatin in plasma, independent of the mode of reconstruction in pigs.

AIM: The long-term effects of gastrectomy and various reconstructions of the gastrointestinal tract on fasting plasma levels of gastrointestinal hormones known to contribute to the control of gastrointestinal motor function were evaluated in pigs. MATERIALS AND METHODS: Domestic pigs were randomly selected to sham surgery or total gastrectomy (TG) followed by reconstruction with oesophago-jejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a proximal jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Blood was collected just before surgery and ten weeks later and peptide levels were analysed by radioimmunoassay. RESULTS: Somatostatin levels were sustained at a high level after TG, regardless of the mode of reconstruction, but were significantly lower in sham-operated animals. Levels of vasoactive intestinal peptide (VIP), neurotensin and motilin were unchanged. CONCLUSION: TG by itself leads to high levels of somatostatin long term, however, somatostatin, motilin, neurotensin and VIP are unaffected by the mode of reconstruction.

Jejunal pouch reconstruction but not preservation of duodenal passage after total gastrectomy reduces plasma cholecystokinin and pancreatic polypeptide long term in pigs.

AIM: The long-term effects of reconstructions of the gastrointestinal tract after gastrectomy on plasma levels of gastrointestinal hormones that contribute to food intake controls were evaluated. MATERIALS AND METHODS: Domestic pigs were randomly assigned to sham-surgery or total gastrectomy followed by reconstruction with oesophagojejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Plasma levels of peptides were analysed by radioimmunoassay (RIA). RESULTS: Ten weeks after surgery, levels of cholecystokinin (CCK) and pancreatic polypeptide (PP) were significantly lowered (79.6% and 67.0%, respectively) in animals with a J-pouch, but not in sham-operated animals or animals with OJRY or OJD, as compared to preoperative levels. The levels of neuropeptide Y (NPY) and peptide YY (PYY) remained unchanged, irrespective of the mode of reconstruction. CONCLUSION: J-pouch, but not preservation of duodenal passage after total gastrectomy, lowers levels of CCK and PP, peptides that reduce food intake.

Endoscopic 13C-urea breath test for detection of Helicobacter pylori infection after partial gastrectomy.

BACKGROUND/AIMS: It is difficult to interpret the results of 13C-urea breath test (UBT) in gastrectomy patients because the test urea may pass through the stomach faster. The aim of this study is to evaluate the efficacy of the modified endoscopic UBT for detection of Helicobacter pylori (H. pylori) infection in the residual stomach. METHODOLOGY: An endoscopic UBT was performed in 44 patients who had undergone partial gastrectomy. At endoscopy, 20 mL of water containing 100mg of 13C-urea were sprayed onto the gastric mucosa and an intragastric gas sample was immediately collected through the biopsy channel. Breath samples were collected at 20 min after spraying 13C-urea. RESULTS: The intragastric delta13CO2 value in H. pylori-positive patients was significantly higher than those of 20-minute breath samples. The maximum sensitivity and specificity of intragastric samples were 97% and 100% with cutoff point of 5 per thousand, respectively. The sensitivity and specificity of breath samples at 20 min were 71.4% and 66.7% with cutoff point of 0.6 per thousand, respectively. CONCLUSIONS: An endoscopic UBT was superior to a standard UBT to detect H. pylori infection after partial gastrectomy.

Long-term consequences of total gastrectomy: quality of life, nutritional status, bacterial overgrowth and adaptive changes in esophagojejunostomic mucosa.

OBJECTIVES: The aim of the study was to evaluate long-term quality of life and adaptive changes in the mucosa of the proximal section of the small intestine used for esophagojejunostomy reconstruction in stomach cancer patients after total gastrectomy. MATERIAL AND METHODS: Thirty-one patients who had undergone stomach cancer-related total gastrectomy were included in the study, which spanned a period of 48 to 127 months (79.6 months on the average) after the surgery. The analysis included: a) evaluation of selected biochemical parameters; b) microbiological evaluation of esophagojejunostomic area; c) evaluation of adaptive changes in esophagojejunostomic mucosa using light and electron microscopy; d) quality of life evaluation with a Troidl questionnaire. RESULTS: Quality of life was subjectively rated as good or very good by almost all subjects. The analyzed biochemical parameters were within the range of normal values in all the subjects with the exception of mild abnormalities in alkaline phosphatase and vitamin B12 levels in some patients. Microbiological examination of mucosal specimens from below the esophagojejunostomy revealed significant bacterial flora overgrowth in all the patients, with streptococci being the most abundant species. Light and electron microscopy examination of the epithelium confirmed it was normal and characteristic of a healthy small intestine. CONCLUSIONS: Long-term quality of life in patients after complete stomach resection is considered good or very good, irrespective of the reconstruction method used, and the esophagojejunostomic mucosa of the reconstructed area is normal and typical for a healthy small intestine.

Endoscopic evaluation of patients with partial gastrectomy and iron deficiency.

Endoscopy is indicated for the evaluation of unexplained iron deficiency to rule out neoplasia. Iron deficiency is common in postgastrectomy patients. The endoscopic yield for significant pathology in these patients is unknown but is expected to be lower than for other iron-deficient groups. A retrospective case-control study with 2:1 matching was performed comparing iron-deficient patients (ferritin < or = 50 microg/liter) having prior Billroth I or Billroth II gastrectomy to matched iron-deficient controls with normal gastric anatomy. There were 52 postgastrectomy patients and 113 controls. There were no significant differences between postgastrectomy patient and controls in age, gender ratio, or laboratory test results, with the exception of MCV (88.9 +/- -1.1 vs 86.0 +/- -0.8, mean +/- SEM, P = 0.048) There were no significant differences in the prevalence of upper gastrointestinal pathology (24.5% vs 29.2%), large (>1 cm) colon polyps (8.3% vs 5.2%), or the presence of any adenomatous colon polyp (28.6% vs 18.9%). There were no malignancies. In conclusion, prevalence of clinically significant pathology is similar for postgastrectomy and nonpostgastrectomy iron-deficient patients. Endoscopic evaluation of iron deficiency should not differ in postgastrectomy patients.

Different characteristics of carcinoma in the gastric remnant: histochemical and immunohistochemical studies.

Seventy cases of cancer of the gastric remnant were divided into three groups: 33 cases following surgery for benign disease (group A), and 15 cases occurring more than 10 years and 22 cases occurring within 10 years after the first gastrectomy for malignant disease (groups B and C, respectively). Then mucin histochemical and immunohistochemical studies were undertaken. Billroth-II procedure for anastomosis was most frequently performed in group A. Intestinal metaplasia within the mucosa surrounding the carcinomas was more frequently present in groups A and C with a diffuse distribution. Intestinal-type surrounding mucosa was significantly more frequent in group C. The immunohistochemical expression of p53 protein was most frequently expressed in group B. We conclude that a different mechanism of carcinogenesis exists in these three groups; i) group A: the reflux of duodenal juice especially following B-II procedures leads to progression of the carcinoma. ii) group B: some genetic factor such as p53 may be related to the metachronous multiple carcinogenesis. iii) group C: metachronous multiple carcinogenesis within the short interval may be closely associated with diffuse intestinal metaplasia in the surrounding mucosa.

Prevalence and clinical importance of Helicobacter pylori infection in patients after partial gastric resection for peptic ulcer disease. A prospective evaluation of Helicobacter pylori infection on 50 resected patients compared with matched nonresected controls.

UNLABELLED: There have been only a few surveys on the prevalence of persistent Helicobacter pylori (Hp) infection in patients who have undergone surgery for peptic ulceration. The aim of the study was to evaluate the prevalence and clinical importance of Hp infection after partial gastric surgery due to peptic ulcer disease. METHODS: We examined 50 patients who had partial gastric resection for peptic ulcer disease and years later underwent upper gastrointestinal (GI) endoscopy. 50 controls matched with respect to indication for GI endoscopy, age and gender were also studied. Three specimens from the fundus of gastric remnant were examined for Hp infection (histology and rapid urease test). The prevalence of Hp infection and pathology findings were compared between the two groups using chi-square statistics. RESULTS: 32 men and 18 women were examined (40 x BII, 10 x BI). The prevalence of Hp infection was 38% in the resected group compared to 60% in the control group (p = 0.015). We found a significant association (p = 0.0004) between Hp infection and endoscopic findings in the control group but not in the group of partially resected patients (p = 0.66). CONCLUSION: The prevalence of Hp infection in hospitalized patients with partial gastric resection is significantly lower than in matched controls. Hp infection does not play a significant pathogenic role in recurrent ulcer after partial gastric resection in these patients.

[The enterochromaffin-serotonin system and Helicobacter infection in the mechanisms of the staged development of peptic ulcer]. / Enterokhromafinno-serotoninova systema i khelikobaktriina infektsiia v mekhanizmakh stadiinoho rozvytku vyrazkovoï khvoroby.

Submitted in this article are scientific propositions and problems concerning the way ulcer disease (UD) of the gastroduodenal system (GDS) develops through its particular stages, and pathosanogenous role which the enterochromaffin-serotonin system (ECSS), a part of the diffusive neuroendocrine APUD-system of the organism, has in it, along with etiopathogenetic role Helicobacter infection plays in the gastroduodenal mucosa (M). Experience gained by the authors with prospective comprehensive evaluation and treatment of 310 patients with chronic gastroduodenitis (CGD), 198 UD GDS patients and 350 of those surgical patients who had undergone resection of the stomach for complicated UD GDS, indicates that all above pathological states share common etiopathogenetic, clinical, histomorphological and microbiological (Helicobacter infection) features, which facts suggest a common pathomorphogenesis of CGD, erosive GD, UD GDS and postgastroresectional UD, and a staged character of erosive-ulcerous transformation in the GDS M, with the hypercoagulative sings being present at the level of hemomicrocirculation. Progressing structural and functional changes in ECSS parallel to stages of development and severity of the UD GDS course suggest their interrelationship to pathosanogenesis during all stages of erosive-ulcerous transformation. At the molecular level, this may reflect directly the course of staged ulceration and a point of activation of processes of physiological defence, this being of diagnostic as well as prognostic value. The enterochromaffin-serotonin conception of pathosanogenesis of staged erosive-ulcerous transformation in GDS M supplements, rather than contradicts to a current infectious Helicobacter hypothesis of ulcerogenesis. Thus, evaluation of ECSS structural and functional status in UD GDS is to be part of a diagnostic algorithm testing severity of the course as well as of a monitoring of treatment and prognostication.

Ultrastructural changes in the small bowel epithelium after total gastrectomy.

The purpose of the study was to analyze ultrastructural changes in the small bowel mucosa in patients after total gastrectomy. We studied mucosal specimens obtained from 25 patients during control gastroscopy. The specimens were routinely processed for examination in transmission electron microscopy. Early after the operation (up to 6 months) we observed marked inflammatory reaction, disordered architecture of the small bowel mucosa epithelium, the presence of dysplasia-like changes and foci of dysplasia. Later on the structure of the mucosa returned to normality. Only a few dysplastic changes were seen. No relationship was found between altered epithelial structure and type of operation. In conclusion, the epithelium of the small bowel does not transform to a gastric type epithelium.

[Endoscopic and immunomorphological changes in the mucosa of the operated stomach]. / Endoskopicheskie i immunomorfologicheskie izmeneniia slizistoi obolochki operirovannogo zheludka.

The method of dynamic endoscopic observation was used in examination of 288 patients after resections of the stomach. Four types of the inflammatory reaction of the gastric stump mucosa and of the anastomosed intestine were found out depending on the degree and spread of the inflammatory alterations during the postoperative period. A correlation was established between the type of inflammatory and immunomorphological changes and the probability of the appearance of peptic ulcer of the anastomosis.

Preservation of the lower esophageal sphincter during total gastrectomy for gastric cancer to prevent postoperative reflux esophagitis.

The lower esophageal sphincter (LES) is usually removed during total gastrectomy to successfully perform a curative operation. In this study, the preservation of the LES in curative total gastrectomy was attempted to reduce the reflux. An experimental study using dogs has revealed that the high-pressure zone of the LES can be preserved by making a resection at the gastroesophageal junction, which thus helps to protect the reflux. A previous clinicopathological study revealed that the LES can be preserved without any fear of recurrence at the resection site, if the tumor is located more than 2.0 cm and 3.0 cm from the gastroesophageal junction to the oral margin in node-negative and -positive cases, respectively. Clinically, 8 patients underwent an LES-preserving total gastrectomy [LES(+) gastrectomy] while 19 had an LES(-) gastrectomy in the same period. Of the five LES(+) cases examined, all showed a high pressure zone, whereas none of the four LES(-) cases examined showed such a high-pressure zone after the operation. Endoscopic examination showed that only one of the seven LES(+) cases but six of nine LES(-) cases revealed esophagitis.

[Lymphoma of the residual gastric stump]. / II linfoma del moncone gastrico residuo.

The authors report a case of non-Hodgkin's lymphoma (lymphoplasmocytoid type) arisen on the gastric stump of a patient operated 18 years before according to Billroth II gastric resection for peptic ulcer. They underline the extraordinary rarity of the event because this type of neoplasia never arises on the gastric stump, where would be more likely to find, due to irritative chemical stimuli of the biliary reflux, phenomena of intestinal metaplasia or severe dysplasia highly predisposing to adenocarcinomas. Furthermore, they stress the importance of a "deep" bioptic examination for a diagnosis as early as possible of this type of pathology.

[Operations on the stomach with a Roux anastomosis]. / Operatsii na zheludke s anastomozom po Ru.

In order to prevent complications such as reflux gastritis, reflux esophagitis, erosions, ulcers and tumors of the gastric stump the Roux anastomosis was used in 497 patients. Among them there were 194 patients after distal resection of the stomach, 239--after extirpation of the stomach, 45 after vagotomy, antrumectomy, 19 after reconstructive operations on the stomach. These patients had organic complications much more rarely: 3.7% had reflux esophagitis (after resection of the stomach on the short loop and with Brown anastomosis--in 50.5%), 12.5% (85.4%) had reflux gastritis, 3.66% (23.7%) had erosions and ulcers of the gastric stump, 2.1% (21.5%) had polyps and carcinomas of the gastric stump. Postoperative lethality was 3.09 and 7.12%.

[Animal experiment studies of development of anastomosis ulcers after reflux-inducing and reflux preventing stomach resection]. / Tierexperimentelle Untersuchungen zur Genese von Anastomosenulzera nach refluxbelasteter und refluxverhütender Magenresektion.

In an animal experiment the role of bile reflux in development of anastomotic ulcer after partial gastrectomy was investigated. On 45 pigs 2/3 partial gastrectomies and on 5 animals only laparotomies were carried out. The ulcer risk after reconstruction procedures with possible bile reflux was compared with reflux-free techniques. Anastomotic ulcer developed after maximal exposure of the gastric remnant to bile as well as after reflux-free reconstructions: B-II-Roux, 40 cm jejunum loop (n = 5/10); B-II-Roux, 20 cm jejunum loop (n = 3/5); B-II-Roux, 40 cm jejunum loop and truncal vagotomy (n = 1/5); B-I and choledochojejunostomy (n = 2/10); B-II-Roux, 40 cm jejunum loop and cholecystogastrotomy (n = 4/5). After B-I resection with medium duodeno-gastric reflux (n = 0/10) and in the control group (n = 0/5, laparotomy only) no ulcer occurred. Because basal acid output after B-I and B-II-Roux resection was reduced to O mval/h, stimulated gastric acid seems to be important in development of anastomotic ulcer. The experimental results prove the protective role of postresectional duodenogastric reflux. After partial gastrectomy for primary ulcer surgery reconstruction procedures guaranteeing duodenogastric reflux should be preferred to Roux-en-Y gastrojejunostomy.

[Absorption disorders following gastric resection--morphological and enzyme-histochemical observations on the small intestinal mucosa].

For the purpose of studying digestion and absorption disorders following stomach surgery, particularly with respect to membrane digestive functional disorders, morphological and enzyme-histochemical observation of the small intestinal mucosa was performed, and a comparison was done between the partial gastrectomy group (59 cases), and the total gastrectomy group (52 cases). The following results were obtained: 1) The small intestinal mucosa showed a tendency to significant villous atrophy in post-operative groups. 2) There was a significant decrease in the disaccharidase activity, especially in the small intestine of the total gastrectomy group. ALP, LAP and gamma-GPT activity also decreased, or disappeared in the small intestines showing villous atrophy. 3) In the atrophied mucosa which showed a marked decrease in membraneous enzyme activity, poorly-formed, irregularly sized microvilli accompanied by glycocalyx irregularity and disappearance were recognized under the electron microscope. The above mentioned morphological and enzyme-histological findings in the small intestinal mucosa, were strongly reflected in both post-operative progress and clinical symptoms.