Regular Scintigraphic Measurements of Food Transit Following Different Types of Reconstruction After Total Gastrectomy FREE

POSTPRANDIAL discomfort and malnutrition are common problems for patients after total gastrectomy. Since Schlatter performed the first successful total gastrectomy in 1897, numerous types of gastric replacements with various enteric reservoirs have been applied in an effort to improve symptoms and the nutritional status of patients following gastrectomy. The construction of a gastric substitute pouch has been proposed to ameliorate postprandial symptoms. The preservation of the duodenal passage—in contrast to the Roux-en-Y anastomosis—should result in better physiological enrichment of the chyme with bile and pancreatic juice and better physiological regulation of gastrointestinal hormones. The optimal pouch size and the functional effects of the jejunal pouch (JP) have not yet been determined.^1- 9 Additionally, there is little known about food transit after different modes of reconstruction for gastrectomy. Moreover, the development of the enteric reservoir, or "pouch," function of gastric replacement has not yet been objectively compared with a jejunal segment interposition without a pouch. For this reason we evaluated the enteric reservoir function of a pouch reconstruction following a total gastrectomy by examining scintigraphic findings of the intestinal transit of a test meal. These results were compared with the development of body weight and food consumption patterns postoperatively.

From 1995 to April 1997, 27 patients in the Department of Surgery of the Charité, Humboldt-University, Berlin, Germany, were enrolled in the study after undergoing total gastrectomy owing to gastric cancer. After resection and D2-lymphadenectomy under curative intention (R0-resection), the patients were randomized intraoperatively to 1 of 3 different types of reconstructions: (1) esophagoduodenal interposition of a 40-cm isoperistaltic jejunal segment without a JP (jejunal interposition without pouch [JIP] group) (n=8); (2) esophagoduodenal interposition of a 47-cm isoperistaltic jejunal segment with a proximal 7-cm JP (JIP with a 7-cm pouch [JIPP 7 cm] group) (n=10); (3) and esophagoduodenal interposition of a 55-cm isoperistaltic jejunal segment with a proximal JP of 15 cm (JIP with a 15-cm pouch [JIPP 15 cm] group) (n=9) (Figure 1).

The anastomoses between the esophagus and the jejunal loop and the jejunal loop and the duodenum were performed with a circular stapler (CEEA 25 Auto-Suture; United States Surgical Corp, Norwalk, Conn). The pouch itself was constructed using a GIA-60 stapler (Auto-Suture; United States Surgical Corp). The 3 groups were homogeneous regarding age, sex, and tumor stage (Table 1). The median operating time was 210 minutes (range, 122-335 minutes).

Scintigraphy was performed in a standardized fashion: following an overnight fast, the patients consumed 60 mL of rice pudding labeled with technetium Tc 99m within 3 minutes. Each patient was placed in front of a gamma camera in a seated position, and the radioactivity was measured in the region of interest. The region of interest was defined as the area between the proximal and distal anastomosis of the interposed jejunal segment, which was marked by a pen on the skin after an x-ray film was taken of the segment. In each patient the half-emptying time was measured. Scintigraphic examinations were accomplished after preestablished postoperative periods of 14 days and 3, 6, and 12 months.

In all groups body weight was measured at the time of scintigraphy. At each follow-up visit, the patients were questioned about their food habits using a special questionnaire module. These questions addressed the number and quantity of meals consumed and changes in dietary restrictions. All data were recorded with a score from 1 to 4 (1, satisfactory, no problems; 2, minor problems; 3, moderate problems; 4, major problems).

The level of significance was defined as P<.05; for statistical tests, the Kruskal-Wallis, Mann-Whitney test, and the Wilcoxon rank sum test were used. Approval of the investigations had been given by the Ethics Commission of Humboldt-University.

Two weeks postoperatively, the mean half-emptying time in the JIP group was shorter than the times in the JIPP 7 cm and the JIPP 15 cm groups (P=.005, JIP vs JIPP 7 cm; P=.012, JIPP 7 cm vs JIPP 15 cm). While the food transit time for the JIP group remained constant for the initial 6 months, the half-emptying time increased in both pouch groups. Twelve months postoperatively, the JIPP 15 cm group had a significantly prolonged scintigraphically measured food transit time compared with the JIPP 7 cm and the JIP groups (Table 2).

In all groups the body weight (percentage of preoperative weight) decreased until 6 months postoperatively. In the JIPP 15 cm group, body weight was clearly regained after 12 months. The JIPP 15 cm group nearly achieved their preoperative body weight after 1 year (Table 3).

In all groups the food consumption patterns changed postoperatively. The JIPP 15 cm group tended to have a better recovery to normal dietary patterns (4-5 meals of normal quantity per day) (Table 4).

The best type of reconstruction after total gastrectomy remains controversial.^7,10- 14 Because postprandial discomfort and malnutrition are common problems for patients following gastrectomy, the aim of all of the types of gastric replacements with various enteric reservoirs is improvement in the patient's quality of life. The construction of a substitute gastric pouch has been proposed by some authors as a means of ameliorating postprandial symptoms and enhancing nutritional intake.^5,13- 15 The optimal pouch size and the functional effects of the JP have not yet been determined. To maintain the transit of food duodenally, some surgeons prefer the Longmire procedure with interposition of a jejunal segment between the esophagus and the duodenum.^{8- 9,16- 17}

Examinations to evaluate food transit after different types of reconstruction following a total gastrectomy are difficult to reproduce. Radiographic tests conducted after patient ingestion of a barium meal (liquid barium, barium enteric-coated granules, or a barium burger) are not quantitative, and the barium is unsuitable for a quantitative evaluation because the weight of the contrast medium is higher than that of normal food.¹⁸ The most sensitive technique for determining abnormalities of gastric emptying is to use the gamma-emitting radionuclide ^99mTc–test meal, which enables tight binding to occur between the radioactive tracer and solid food.¹⁸ Isotopic methods were also used because they involve less radiation exposure for the patient compared with fluoroscopy and are well accepted by the patient.^{12,15,18- 20} To our knowledge, all published studies that evaluate food transit after gastrectomy and reconstruction with a JP refer to only 1 postoperative measurement, mostly taken 1 year postoperatively. No reliable continuous data exist analyzing the functional development of a gastric reservoir after pouch reconstruction over a period of time. Furthermore, to our knowledge, in all previous studies, different barium meals or radioactively labeled meals have been used for radiographic determinations, for instance rice, eggs, beef, or cake.^16,18- 20

Only a limited comparison between the results of various studies is possible. Takeshita et al¹² described the pouch examination with a barium meal and radiopaque markers. The authors revealed favorable retention of the barium meal in the JP and satisfactory bowel motility, as measured by the percentage of radiopaque markers that were expelled from the pouch. However, these examinations were performed only once—6 months or longer—postoperatively.

The scintigraphic examination results of our trial demonstrate the development of a possible enteric reservoir function of the JIPP 15 cm beginning after the sixth postoperative month. In the JIPP 7 cm and JIP groups, only a small or no enteric reservoir function was shown in the scintigraphic measurements compared with the JIPP 15 cm group. The findings of our trial support the results of Tanaka et al.²¹ Their studies suggest that differences in JP length—even of only 5 cm—might play a role in postoperative food consumption patterns and thus influence postoperative symptoms and metabolism of patients who underwent gastrectomy.^14,16,20 The patients in the JIPP 7 cm group showed a decreased half-emptying time after 1 year compared with the examinations conducted 3 and 6 months postoperatively. This fact may be explained by disturbances of emptying of the interposed jejunal loop the first time postoperatively. Special measurements like manometry could be helpful in answering this question.

The scintigraphic measurements are not completely without mistakes and depend on many physiological alterations. This is a possible explanation of the great amount of SD in the different groups of our trial. Nakane et al²⁰ described different types of emptying patterns after pouch reconstruction: delayed, intermediate, and rapid type. Stier et al²² reported that the emptying rate of a JP is delayed compared with that of patients with a normal stomach. In contrast, Pellegrini et al²³ described a slower bowel transit by a Roux-en-Y esophagojejunal anastomosis in patients who underwent total gastrectomy compared with normal controls.

Sufficient food intake is fundamental for patients who have undergone gastrectomy.¹³ In our trial, patients in the JIPP 15 cm group are the only ones who nearly achieved their preoperative food consumption patterns (normal amount of meals, 4-5 per day). This was especially so for those patients with a large pouch who came close to their preoperative body weight after 1 year and had only minor nutritional problems, indicating that a smaller pouch (7 cm) does not suffice. In their study Troidl et al¹³ described the development of food intake after gastrectomy and the recovery of the patients with a Hunt-Lawrence Rodino pouch compared with a Roux-en-Y reconstruction 6 months postoperatively. Patients who underwent a Roux-en-Y reconstruction did not exceed half of the preoperative food intake on average in contrast to patients with a pouch reconstruction. In the results of our trial, the better clinical outcome of the patients who underwent a large pouch reconstruction seems to be explained by the development of the pouch reservoir 6 months postoperatively. A large pouch can be assumed to considerably support the patient's nutritional needs after total gastrectomy.

This leads to the question, in which case should a pouch reconstruction be considered? Because an enteric reservoir function will show no significant yield before the sixth postoperative month, the chances of survival for the patient should be at least 1 year from the time of diagnosis. Only patients with a postoperative prognosis of at least 1 year will profit from an improved quality of life.¹³ If the resection is considered to be palliative treatment, then a simple reconstructive procedure, such as a Roux-en-Y or loop jejunostomy, is a sensible option.

Jejunal interposition between the esophagus and the duodenum with a 15-cm pouch reconstruction can lead to a prolonged food transit time with enteric reservoir function. Whether the pouch reconstruction should be considered as the treatment of choice for reconstruction after total gastrectomy for patients who have a chance of surviving for at least 1 year must be studied further and include more examination into the quality of life.

We thank Noga E. Meiri for preparing the manuscript.

Corresponding author: Beatrix Hoksch, MD, University Department of Surgery, Charité, Humboldt-University, Schumannstrasse 20/21, D-10117 Berlin, Germany.