Operative technique on nearly total gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of vagal nerve, lower esophageal sphincter, and pyloric sphincter for early gastric cancer

Nearly total gastrectomy preserving the vagal nerve, the lower esophageal sphincter (LES), and the pyloric sphincter was developed as a function-preserving surgical technique to improve postgastrectomy disorders. In this paper, application criteria and technique are outlined, and postoperative quality of life was clinically investigated. Ten subjects who underwent this surgical operation (group A: 7 male and 3 female subjects at age 48 to 68 years with a mean age of 58.3 years) were interviewed to inquire about reflux esophagitis, dumping syndrome, and microgastria. Group A was compared with 20 cases of conventional total gastrectomy with D2 lymphadenectomy, excision of the lower esophageal sphincter (LES), total vagotomy, and single jejunal interposition (group B: 16 male and 4 female subjects at age 48 to 72 years with a mean age of 63.9 years). Included were cases with early cancer (M or SM1 of NO) localizing at the middle third and lower stomach, which was not applicable to endoscopic excision of gastric mucosa or partial gastric excision in M cancer, 2 cm or farther from the margin of the cancer to the esophagogastric mucosa cephalad junction and 3.5 cm or farther from the margin of the cancer to the pyloric caudad sphincter; in SM1 cancer, 4 cm or farther from the oral-side margin of the cancer to esophagogastric mucosa junction and 5.5 cm or farther from the anal-side margin of the cancer to the pyloric sphincter. In excision with lymph nodes, hepatic and celiac branches bifurcating from anterior and posterior trunks of the vagal nerve were preserved. To preserve LES, the esophagus was severed at the His angle at right angle to the longitudinal axis of the esophagus. The antrum was severed at 1.5 cm from the pyloric sphincter, preserving the arteria supraduodenalis. An alternative gaster was created as a 15-cm jejunal pouch with a 5-cm jejunal conduit for orthodromic peristaltic movement, using an automatic suture instrument to complete side-to-side anastomosis of folded jejunum with 1- to 1.5-cm long upper end of the pouch not anastomosed. The abdominal esophagus was mechanically anastomosed with a jejunal pouch, and anastomosis of the pyloric antrum with a jejunal conduit was manually completed by stratum anastomosis. In group A, food ingestion per time could be taken the same as that of a healthy person, with no reflux esophagitis and dumping syndrome being noticed. Reflux esophagitis developed more significantly in group B than in group A (p<0.05). In food ingestion per time, group B was significantly delayed compared with group A (p<0.05). The present results suggested that the surgical technique proposed is a function-preserving gastric surgery appropriate to prevent postgastrectomy disorder of subjects.