Int J Colorectal Dis (2002) 17:268–274 DOI 10.1007/s00384-001-0375-2

J. Metzger L. Degen F. Harder M. von Flüe

Accepted: 17 October 2001 Published online: 5 March 2002 © Springer-Verlag 2002

J. Metzger (✉) · F. Harder Departement Chirurgie, Universitätsspital Basel, Spitalstrasse 21, 4031 Basel, Switzerland e-mail: [email protected] or [email protected] Tel.: +41-61-2652525 Fax: +41-61-2657321 L. Degen Gastroenterologie, Universitätsspital Basel, Petersgraben 4, 4031 Basel, Switzerland M. von Flüe Chirurgische Klinik A, Kantonsspital Luzern, 6000 Luzern 16, Switzerland

O R I G I N A L A RT I C L E

Subjective and functional results after replacement of the stomach with an ileocecal segment: a prospective study of 20 patients

Abstract Background and aims: The optimal reconstruction procedure after gastrectomy is still a matter of debate. The ileocecal interpositional graft offers an excellent reservoir capacity, the preservation of duodenal passage, and a natural antireflux barrier (ileocecal sphincter). Patients and methods: We prospectively analyzed the quality-of-life outcome in 20 patients undergoing ileocecal interpositional graft (13 subdiaphragmatic reconstruction, 7 intrathoracic reconstruction) after gastrectomy in a University Hospital and a Canton Hospital (mean followup 6 months), operative and postoperative morbidity, body weight, reflux, and dumping symptoms. In a smaller series of nine patients we performed functional tests such as gastric emptying measurements, glucose tolerance tests, and manometry of the gastric substitute.

Introduction Reconstruction procedures after gastrectomy have long been a controversial issue. In 1887 Schlatter performed the first successful gastrectomy with an end-to-side esophagojejunostomy. During the early history of gastric surgery the main goal was survival during the immediate perioperative and postoperative periods. Currently there is greater emphasis on morbidity and its impact on quality of life. After total gastrectomy the primary problems are loss of reservoir function, exclusion of the duodenal route, and intestinal alkaline reflux. Heberer et al. [1] describe more than 60 different postgastrectomy recon-

Results: The mean gastrointestinal quality-of-life index in the subdiaphragmatic reconstruction group 114, and that in the intrathoracic reconstruction group was 106. Mild reflux and dumping symptoms were noted by no patients in the former group and by two of seven patients in the latter. In the smaller series of nine patients gastric emptying time was faster in the intrathoracic group, but no difference in plasma glucose level was found between the two groups. Conclusions: Reconstruction after gastrectomy with an ileocecal interpositional graft achieves good quality of life with an acceptable morbidity. The technique seems to reduce the occurrence of postoperative reflux and dumping symptoms. Keywords Ileocecal interpositional pouch · Quality of life · Roux-en-Y reconstruction · Total gastrectomy

struction procedures. These differ primarily in the origin of the graft (small or large intestine), the configuration and size of the reservoir, and the conservation or exclusion of the duodenal passage. There is still no “best” reconstruction procedure after gastrectomy. The optimal stomach replacement should be sufficiently large for a reservoir, preserve the duodenal route, and prevent alkaline reflux. In 1997 we published our technique using the ileocecal interpositional graft for gastric replacement [2]. A technique was first described and performed on animals and man during the 1950s [3, 4]. The cecum, with its excellent compliance function as a short-term reservoir, was described by Hurst [5] in

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1931 as the “stomach of the colon.” It is preshaped by the gastrointestinal tract and has an antireflux barrier (ileocecal valve). The ileum extends in an archlike fashion into the lumen of the cecum and is attached in this position by external ligaments [6]. The valve prevents reflux into the terminal ileum at pressures up to 80 cm of water column in the cecum. Severing these external ligaments eliminates the valve effect [7]. Additionally, in the area of the Bauhin (ileocecal) valve one notes an increased density of elastic fibers [6]. The fact that the ileocecal segment can be used with its blood and nerve supply intact without the need to increase its capacity by constructing an intestinal pouch underscores its suitability in this procedure. In contrast to other reconstruction techniques, the intestinal wall is not split-opened longitudinally in order to create a pouch at this site preserving the extrinsic and intrinsic neural connections. Within the past 3 years reports have appeared in the literature about the use of this procedure. Uras et al. [8] interposed an ileocecal segment in six patients after pylorus-preserving gastrectomy. Two large series from Japan [9, 10] showed excellent results using the ileocecal interposition with little perioperative morbidity and no postoperative dumping or reflux problems. Since commencing our study we have performed this interpositional graft as a gastric replacement in 31 patients. To date 20 patients have been followed postoperatively for 6 months. These results reflect a pilot study demanding the feasibility and the dependency of a technique with excellent early results. We present the periand postoperative outcomes on these patients, measuring morbidity, weight development, dumping and reflux symptoms, and quality of life. In a series of nine patients we also performed functional tests such as scintigraphic gastric emptying and glucose tolerance measurements.

Patients and methods Patients Between January 1996 and November 1998 we recorded data on 20 consecutive patients (14 men, 6 women; mean age 62.4 years, range 41–79, median 63.6) with either gastric or distal esophagus cancer who underwent reconstruction with an ileocecal interpositional graft at the University Hospital Basel and Cantonal Hospital Lucerne, Switzerland. Ten patients had an adenocarcinoma at the gastroesophageal junction or the lower esophagus and ten a gastric cancer. The indications for this type of reconstruction were: UICC tumor stage 2 or 3, M0; R0 resection; and an unremarkable colonoscopy. The study protocol was approved by the university ethics committee. Thirteen underwent gastric resection followed by reconstruction with the ileocecal interpositional graft through a single abdominal approach, and seven had a transthoracic esophageal resection and an intrathoracic reconstruction with the ileocecal segment.

Fig. 1 Ileocecal interposition as gastric replacement. 1 Esophagoileostomy; 2 cecum; 3 coloduodenostomy; 4 ileotransversotomy

Operative procedure A colonoscopy was performed preoperatively to exclude significant pathology in the cecum. The operative procedure [2, 11] began with total gastrectomy and lymphadenectomy. The ileocolic segment (ileum length approx. 5–7 cm; cecum length approx. 15–18 cm) was mobilized together with the ileocolic artery. In cases involving cancer of the cardia in which an intrathoracic reconstruction was planned after gastrectomy and distal esophagus resection the ileocolonic segment was mobilized with the right colic artery to permit the interpositional graft to be placed further cephalad in the thorax without tension. An appendectomy was performed. After sectioning the intestine in the area of the ascending colon and terminal ileum the segment was rotated clockwise 180° in the upper abdomen. The ascending colon was attached endto-end to the duodenum with a single row of continuous sutures to include all layers in the area of the posterior wall and with an extramucosal suture in the area of the anterior wall. The ileal end of the graft was then anastomosed to the distal esophagus either endto-end or side-to-end (Fig. 1). Restoration of gut continuity was completed with an ileoascendostomy. Operative times from skin to skin closure averaged 410 min (range 240–540, median 406). As suture material we used either 4-0 Maxon or 4-0 Monocryl. Anastomotic integrity was checked using a water-soluble contrast medium swallow on the 6th postoperative day. Blood transfusions were required by five patients. There were no in-hospital deaths. Follow-up The patients recorded their weight once weekly during the first 24 months, and all the patients were seen by one of the surgeons (J.M.) 6 months after surgery. A clinical examination and an interview covered dumping and reflux symptoms and an evaluation of

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the quality of life was performed at this time. The gastrointestinal quality-of-life index (GIQLI) of Eypasch et al. [12] was assessed a mean of 6.3 months after the operation. The validated questionnaire was used containing 36 questions each with five response categories. Apart from disease-specific items the questionnaire deals with general physical, psychological, and social items. The responses to questions are given a numerical score (maximum 144 points). Endoscopy of the new gastric substitute was performed 4–6 months after surgery by one of the attendant gastroenterologists. Functional tests Of the 20 patients 9 agreed to undergo further functional tests (6 after subdiaphragmatic reconstruction and 3 after intrathoracic reconstruction). Gastric emptying measurement Gastric emptying of a solid meal was measured using a noninvasive scintigraphic method developed in recent years [13, 14]. Polystyrene amberlite 410 resin pellets (average diameter 1 mm; range 0.5–1.8 mm) were labeled with 1 mCi 99mTc to provide a solid food marker. The efficiency of the labeling has been shown to exceed 98%, judged by thin layer chromatography [13]. A “standardized meal” was mixed with the 99mTc-labeled pellets and given to the patients. Gamma camera imaging was started immediately after completion of ingestion of the radiolabeled meal with a large field-of-view gamma camera with a medium-energy, parallel-hole collimator. Ventral and dorsal images were acquired with the patient standing erect. For the 99mTc counts a 140-keV energy window (±20%) was used. For each image 2-min acquisitions was selected. Using variable regions of interest, the radioactivity was quantitated in the gastric substitute. The geometric means of the counts obtained from anterior and posterior images were calculated for each region and then corrected for radionuclide decay. Glucose tolerance test Patients were fasted overnight. At 8:00 a.m. a blood sample was taken. Thereafter the patients ingested 75 g glucose with 200 ml water, and blood samples were taken every 30 min for the next 3 h. Fig. 2 Changes in body weight in 20 patients during the first 24 postoperative months

Statistical analysis Gastric emptying rates and glucose tolerance tests were evaluated by analysis of variance. Statistical significance was set at P<0.05.

Results Four of the 20 patients developed complications related to surgery (20%). Two patients had an anastomotic leak. One of these required a laparotomy on day 7 after surgery. A small leak was found at the esophagoileostomy, which was oversewn and drained. He concomitantly developed pancreatitis with a pancreaticocuteanous fistula. The patient was discharged day 118. Another patient was treated conservatively by drainage, delayed oral feeding, a feeding jejunostomy, and antibiotics and was discharged on day 56 without symptoms. Pneumonia and atelectasis occurred in five patients (25%). The mean hospital length of stay was 17 days (range 13–118, median 17). All patients lost weight during the first 3 months after surgery. From the 4th month patients started to gain weight or maintained a steady state (Fig. 2). Two of the seven patients who underwent an intrathoracic reconstruction developed either early or late dumping symptoms. Another two patients of this group suffered from Table 1 Reflux and dumping symptoms 6 months after surgery Symptoms

Subdiaphragmatic group (n=13)

Intrathoracic group (n=7)

Dumping Early Late

0 0

1 1

Reflux

0

2

Gas bloat

2

0

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Fig. 3 Quality of life according to the Eypasch score [12] 6 months after ileocecal interpositional graft (n=20). Black bars Individual scores of patients with subdiaphragmatic reconstruction (n=13); gray bars scores of those with intrathoracic reconstruction (n=7)

Fig. 4 Results of gastric substitute emptying test 9 months after surgery, separately showing the intrathoracic and the subdiaphragmatic reconstruction groups. In comparison the emptying curve of an age- and gender-corrected nonoperated population

mild reflux symptoms 6.3 months after surgery. None of the abdominally reconstructed group developed either dumping or reflux symptoms, but two patients described symptoms similar to the gas bloat syndrome (Table 1). Individual GIQLI scores are presented in Fig. 3. Patients receiving subdiaphragmatic reconstruction had a mean of 114 points (range 85–128) and those receiving intrathoracic reconstruction 106 points (range 84–126). Four patients who had scores below 100 points complained principally of exhaustion, depression, or nausea. The emptying time of the intrathoracic substitute tended to be faster than the abdominal reconstruction (n.s.) but both were accelerated compared with an age- and gender-corrected control group (P=0.001; Fig. 4). There was no significant difference between the plasma glucose level at any time between the two groups (Fig. 5).

Discussion In our experience the ileocecal interpositional pouch provides a nearly ideal gastric replacement with a large, preshaped reservoir and an efficient valve mechanism. Moreover, the interposition between the esophagus and duodenum preserves the physiological duodenal passage. Various types of reconstruction have been described [1], dealing with the ideal reservoir (pouch), preserving the duodenal passage, and attempting to reduce reflux into the lower esophagus. Several studies [15, 16, 17, 18, 19], some randomized, show conflicting results comparing more complex procedures with the straight forward Roux-en-Y construction, still the widely preferred method.

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Fig. 5 Glucose tolerance test 9 months after surgery

Reservoir Randomized studies have demonstrated the importance of a pouch reconstruction. Maximum tolerable volume and intraluminal pressure are significantly better after creating a small bowel pouch than after Roux-en-Y reconstruction [20]. Although gastric replacement with small or large bowel provides an autonomous motility, neither method offers anything approaching the complex motility of the stomach with its ability to accommodate to different volumes (receptive relaxation) [21]. Despite these differences the weight loss with creation of a reservoir is substantially less than that with a Roux-en-Y diversion [15, 16, 22, 23]. Furthermore, postoperatively quality of life strongly depends on the delayed emptying of the pouch [22].

was regarded as the single most important factor in achieving these results. A normal duodenal passageway is important not only for the resorption of various vitamins, trace elements, calcium, and iron but also for glucose metabolism and for the rapid and thorough mixing of food with digestive enzymes [16, 27]. The effect of a preserved duodenal passage on intestinal transit has the theoretical advantage that the motility of the graft is coupled to that of the duodenum (pacemaker function), and therefore the passage of food in the aboral direction is better synchronized, preventing or reducing dumping symptoms [28]. Indeed, dumping rates are markedly higher with the Roux-en-Y technique (23%) than with jejunal interposition (8%) [29]. Reflux barrier

Duodenal passage In contrast to the accepted functional importance of a pouch, the clinical advantages of a preserved duodenal passage remains uncertain [24]. Reconstructions involving preservation of the duodenal passage were originally performed in 1939 and later described in 1941 [25]. In 1952 the principle of jejunal interposition was taken up again and further developed by Longmire [26]. Preserving the duodenal route, Schwarz et al. [16] prospectively compared the so-called “Ulm pouch,” with the HuntLawrence-Rodino pouch and the simple Roux-en-Y diversion. Six months after surgery the Ulm pouch group had a significantly better quality of life, greater weight gain, and less disturbed glucose tolerance than the other two groups. Preservation of the duodenal passageway

Esophagojejunal plication was introduced as a means for reducing alkaline reflux into the esophagus. In a later modification (Herfarth’s technique) the free jejunal loop is folded around the anastomosis in the manner of a plication [30]. A one-way valve is thus created to provide an antireflux mechanism. Elevated pressure in the neostomach compresses the distal portion of the esophagus. Esophagojejunal plication creates a secure barrier to reflux only when the lower esophageal sphincter is simultaneously preserved. If the lower esophageal sphincter is excised, the barrier to reflux is no longer adequate. To overcome the problems of alkaline reflux Ohwada et al. [31] use the left colon as gastric substitute and additionally pexy the oral end of the left colon to the esophagus to create a new His angle as an antireflux barrier.

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Several studies in dogs and humans have shown that the cecum is large enough to serve as an adequate reservoir [3, 4, 32, 33]. The cecum has also been used in urology as a bladder replacement [34] and in pediatric surgery as a replacement for an atretic esophagus [35]. In 1993 we studied the use of the cecum as a replacement for the rectum [36]. In comparison to more complex pouch reconstructions, the ileocecal interposition graft is a simple, safe technique transposing en bloc a preformed pouch with its integrated valve. It has several important benefits as a gastric replacement: a pouch volume that is technically easy to vary, a built-in barrier to reflux, and the possibility of retaining the duodenal passageway [37]. The morbidity and mortality rates are comparable to those of other methods of stomach replacement. Two of our 20 patients (10%) had an anastomotic leak, one of which was treated conservatively, which is comparable to the leakage rates after esophagosjejunostomy published in larger series [38]. There were no in-hospital deaths. Our results show that none of the abdominally reconstructed patients complained of dumping or reflux symptoms while two of the seven intrathoracically reconstructed patients had mild dumping and reflux symptoms. A very weak gas bloat syndrome, which is possible sequel following fundoplication [39] occurred twice in the group of abdominally reconstructed patients. A possible explanation is disturbance of the sphincter control mechanism. Our patients receiving subdiaphragmatic reconstructions had an excellent GIQLI score, with a mean of 114 points. Patients undergoing intrathoracic reconstruction had generally lower scores. A phase III study [12] measured the validity of GIQLI score in 168 normal individuals, who reached a mean score of 125.8 points. The gastric emptying process of solids after abdominal reconstructions was slower than after intrathoracic

reconstruction, while emptying of fluids (represented by the glucose tolerance test) showed no difference between the two groups. We have previously shown in experiments on the Göttingen minipig that the ileocecal graft can normalize gastric emptying, while a simple Roux-enY reconstruction cannot [40]. Many questions remain to be answered, including the optimal length of the ileal segment, the optimal cecal volume for reservoir function or emptying without stasis, and the possible long-term damage to the colonic mucosa resulting from exposure to bile acids. The most important endpoint of any follow-up study dealing with postgastrectomy and reconstruction problems remains, in addition to overall survival, the patient’s quality of life. Patients with a life expectancy of more than 6 months undergoing curative surgery may benefit from the creation of a pouch with preservation of the duodenal passageway [41]. Food intake, weight changes, small bowel transit, postprandial symptoms, and overall quality of life seem to be better in the long term. In summary, we present preliminary functional data on a promising new gastric pouch reconstruction procedure following total gastrectomy which may be superior to established procedures. Although we present only short follow-up data (6 months), we believe that early superiority is not without importance as these patients often have a rather limited life expectancy. Further prospective randomized studies are warranted comparing the ileocecal interpositional graft with the still preferred reconstruction technique, the Roux-en-Y loop. The crucial factors to be evaluated in such a study must be a normal food intake, weight preservation, dumping and reflux symptoms, and a good quality of life. Acknowledgements The authors acknowledge Mr. Tony Amery, F.R.C.S for his help in reviewing and revising this manuscript.

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