Total gastrectomy for cancer: Is reconstruction or a gastric replacement reservoir essential?

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Abstract
Malnutrition is a frequently observed complication of total gastrectomy. Does the mode of reconstructing the alimentary tract bear part of the responsibility? We assessed our experience from January 1975 to 1992 to analyze this issue. A series of 64 total gastrectomy patients [40 men, 24 women; aged 59±11 (SD) years] were considered. Preoperative and periodic follow‐up evaluations were prospectively documented: upper gastrointestinal series, endoscopic examination, complete blood count, serum and liver biochemistry profiles, serum proteins, tranferrin, serum iron and calcium, iron‐binding capacity, oral glucose tolerance test, ultrasonography or computed tomography, actual and ideal body weight and performance (AJCC/UICC) assessments. Symptoms were classified by means of Cuschieri's scoring system. Esophageal mucosal changes (edema, hyperemia, erosions, ulcerations) were documented on endoscopy. There were 36 of 58 operative survivors who had no evidence of tumor recurrence and were available for long‐term evaluation (12–132 months). An RY loop had been constructed in 25 patients, 5 with a Hunt pouch; 9 had an isoperistaltic jejunal interposition (IJI), 4 with a Kock pouch: and 2 bad a Braun loop. A 60 to 70 cm long jejunal limb was always utilized. Statistical analyses were obtained by means of the Student t‐test and the equality of medians test. Progressive malnutrition was observed in patients with the Braun (omega) loops, both patients displaying persistent esophagitis and dietary restrictions. Both recovered ideal body weight after remedial surgery that transformed the omega loop into an RY loop. Both RY and IJI loops effectively prevented alkaline esophagitis. The observed increase in body weight was 4.5±2.4 kg in 25 RY loop patients and 4.0±2.6 kg in the 9 IJI patients (not significant), with no significant benefit being observed in patients with newly created gastric “replacements.” It was concluded that (1) a technically correct and adequate reconstruction is not followed by significant levels of malnutrition; (2) a simple RY loop is the most suitable method in most instances for total gastrectomy for cancer; (3) an IJI is not justifiable on a routine basis; (4) additional pouches are of questionable value; and (5) omega loops are undesirable.