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Ann Thorac Surg 1995;60:261-266
© 1995 The Society of Thoracic Surgeons
Department of Surgery, Louvain Medical School, Brussels, Belgium
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. The study compares the gastric tube (group A; n = 112) to the whole stomach whose lesser curvature is denuded (group B; n = 100) in terms of technical complication and alimentary comfort. The clinical results are substantiated by assessment of the eating performance of patients and control subjects at a test meal, measurement of the gastric dimensions before and after both tailoring procedures, and intraarterial staining of the gastric wall.
Results. Major differences between the two groups are cervical anastomosis stenoses (22.3% versus 6% [A versus B]; p = 0.008), fistulas (7.9% versus 1%; p = 0.0209), number of meals and snacks per day (4.6 versus 4; p = 0.0275), sensation of early fullness at meals (52.4% versus 17.8%; p < 0.0001), ratings given to the long-term alimentary comfort (presymptomatic condition = 10 points) (7.6 versus 8.8 out of 10 on average; p < 0.0001), and calories consumed in 1 minute at a test meal (59% [p < 0.05] versus 77% of those consumed by control subjects). The volume of the stomach is reduced by a range of 21.4% to 47.2% after tubulization (group A) whereas it increases by a range of 4.9% to 17.4% after denudation of the lesser curve (group B). Intraarterial staining of the gastric wall reveals the poor vascularity of the upper-most segment of the greater curve.
Conclusion. Slight increase of the gastric capacity and maintenance of the submucosal vascular network account for the better results achieved with the whole stomach.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Pulling the stomach up to the neck as an esophageal substitute has received wide acceptance [1–4] because of its extraordinary plasticity and stretchability and the richness of its submucosal vascular network [2, 5, 6]. Nevertheless, variations in patients' gastric anatomy due to both individual and ethnic factors [6, 7] explain the need in white patients for using various lengthening procedures. The classic lengthening technique consists of tubulization of the stomach by stapling resection of the proximal three fourths of the lesser curvature [1, 2, 4]. Drawbacks of this technique are the relatively high risk of cervical anastomosis fistulas and stenoses [8, 9] and the sensation of early fullness that is felt by many patients at or just after a meal [10, 11]. Therefore, from 1988 on, we experimented with a technique of denudation of the lesser curvature that both unfolds the right side of the stomach and maintains the whole gastric capacity and submucosal vascular network [12]. This study compares the two techniques in terms of postoperative technical complication and long-term alimentary comfort.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Surgical Technique
ESOPHAGECTOMY AND PERIGASTRIC DISSECTION.
Esophagectomy was carried out by either right thoracotomy (n = 153), left thoracotomy (n = 5), right thoracoscopy [13] (n = 10), sternotomy (n = 8), or through the hiatus without thoracotomy (n = 36). After division of the esophagus in the neck, the stomach was mobilized by division of the left gastric, left gastroepiploic, and short gastric vessels through a midline laparotomy. The right gastric vessels that provide negligible blood supply to the fundus [5] were either severed or maintained depending on the technique used for gastric tailoring. A pyloroplasty was done routinely.
GASTRIC TAILORING.
Two types of gastric transplant were constructed. The gastric tube with stapling resection of the lesser curvature (group A; n = 112) was used for any indication until 1988, and from 1988 on for distal tumors only, whereas the whole stomach with denudation of the lesser curvature flush with the gastric wall (group B; n = 100) was introduced in 1988 and applied to more proximal tumors and benign conditions.
Gastric tubulization (Fig 1
) is started by division of the lesser omentum 4 to 5 cm proximal to the pylorus over a 1-cm distance for application of a GIA-50 (US Surgical Corp, Norwalk, CT) or a PLC-50 (Johnson and Johnson, Somerville, NJ) stapler on the wall. The distal segment of the first cartridge of staples is applied at an angle of 60 degrees to the right border of the stomach. The next cartridges are applied in totality parallel to and 20 mm away from the free edge of the lesser curvature up to the left side of the cardia. The long staple line is oversewn using interrupted sutures.
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) is carried out by division of the terminal rami of both right and left gastric vessels flush with the gastric wall from the pylorus up to the cardia. The lesser omentum and its lymph nodes are separated from the gastric wall while the right side of the stomach is unfolded. The esophagus eventually is separated from the stomach by application of a single cartridge of GIA or PLC stapler on the cardia. In practice, however, the lower one fourth of the lesser omentum may be maintained and denudation started 4 to 5 cm proximal to the pylorus in those patients having a long stomach or a short distance between the hiatus and the neck without precluding radical lymph node clearance [2, 14].
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Clinical Assessment of the Gastric Transplants
POSTOPERATIVE TECHNICAL COMPLICATIONS.
Cervical anastomosis fistula was defined as any leakage of saliva or methylene blue–stained water through the Penrose drain that was left in the area of the suture line. Cervical anastomosis stenosis requiring endoscopic dilation was defined as any narrowing of the suture line at early follow-up barium swallow study that was responsible for persistent dysphagia.
ALIMENTARY COMFORT AND SOCIAL REHABILITATION (STANDARD QUESTIONNAIRE).
Sixty-one group A patients (mean follow-up, 38 months) and 73 group B patients (mean follow-up, 29.7 months), all having no evidence of neoplastic recurrence after a minimum 6 month follow-up, were interviewed for the presence of foregut symptoms according to a standard questionnaire that included the following questions: How many meals and snacks do you take per day? Are you disabled by arrhythmia, sweating, early thoracic, or epigastric fullness at or just after meals, regular regurgitations, or cervical heartburn? Do you have diarrhea defined as 3 motions per day or more, or liquid stools? How high is your current body weight in reference to the weight you had after operation? Can you rate your current alimentary comfort, if your condition before you began having esophageal problems was rated as 10 points? Have you resumed your preoperative occupational activity?
Objective assessment of the gastric transplants
The following studies were carried out to substantiate the clinical findings. (1) The ability of complete denudation of the lesser curvature to lengthen the stomach was evaluated by measuring the distance between the pylorus and the left side of the cardia before and after the procedure in 34 group B patients at operation. (2) The capacity of the gastric reservoir was measured before and after complete denudation of the lesser curvature as well as after stapling resection of the latter by filling the stomach of 10 fresh cadavers or brain-dead organ donors with water up to a 20 cm H2O pressure through a tube that was inserted into the gastric lumen while both the pylorus and cardia were clamped. (3) The length of the vascular arcade along the greater curvature and that of the greater curvature itself were measured on 11 stomachs from fresh cadavers and brain-dead organ donors. (4) The vessels of 10 stomachs from brain-dead organ donors were flushed with the University of Wisconsin solution. All the vascular pedicles but the right gastroepiploic artery and the two or three uppermost short gastric veins were ligated. Methylene blue– or carmine rose–stained saline solution was injected into the right gastroepiploic artery and progression of the staining front within the gastric wall was observed. (5) Thirty-five of the 86 patients still living at the time of the study, ie, 12 patients of group A (median follow-up, 67.5 months; mean age, 57.3 years) and 23 patients of group B (median follow-up, 42 months; mean age, 61.3 years), as well as 10 healthy residents in surgery (mean age, 28.2 years) and 20 patients' spouses with no histories of previous foregut diseases or operations (mean age, 61.4 years) accepted our invitation to take a test meal. The latter was similar to that given to colon interposition patients by DeMeester and associates [15]. It had a caloric content of 824 calories and consisted of 1 cup of macaroni and cheese and one half cup of green beans, one roll with one teaspoon of margarine, two peach halves, one ounce of pound cake, and 200 mL of fresh water. Both patients and control subjects were advised to eat the meal as they would have done at home and without talking to their neighbors. The number of calories consumed in 1 minute (eating rate) as well as the percentage of available calories consumed (meal capacity) were calculated for each patient and control subject.
Statistics
The Fisher's exact, Kruskal-Wallis, Dunn's multiple comparisons, and Mann-Whitney tests were used when appropriate.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Cervical anastomosis stenoses were significantly more frequent in group A (n = 25; 22.3%) than in group B (n = 6; 6%) (p = 0.0008) and required more sessions of endoscopic dilation to subside in group A (mean, 5; range, 2 to 15) than in group B (mean, 2.3; range, 2 to 3) (p = 0.0199). Likewise, the prevalence of cervical fistula was significantly higher in group A (n = 9; 7.9%) than in group B (n = 1; 1%) (p = 0.0209), and none of the patients with a negative methylene blue test had development of deep cervical abcess. All fistulas but one healed by prolonged fasting and total parenteral nutrition. One fistula that was complicated by a tight stricture in 1 group A patient required surgical revision. Altogether, cervical anastomosis complications (fistulas plus stenoses) in combined groups A and B occurred more frequently with substernal transplants (37.2%) than with mediastinal transplants (13.5%) (p = 0.0004). However, for each location, those complications were more frequent in group A than in group B, ie, substernal tubes (44.1%) versus substernal whole stomachs (0%) (p = 0.0192) and mediastinal tubes (21.4%) versus mediastinal whole stomachs (7.6%) (p = 0.0110). On the other hand, three pyloric stenoses in group A were treated either by balloon dilation (n = 2) or by revisional operation (n = 1).
In all, technical complications were more frequent in group A (33 patients; 29.4%) than in group B (11 patients; 11%) (p < 0.0001). They were responsible for the death of 0.9% of the patients, whereas overall in-hospital mortality was 4.2% (<30 days, 1.4%; >30 days, 2.8%; 203 patients discharged to home).
LATE OBSTRUCTION OF THE UPPER DIGESTIVE TRACT.
Sixteen of the 212 patients (7.5%) experienced dysphagia at follow-up. Fifteen patients were treated by dilation or laser therapy for stenoses due to reflux (n = 2), or radiotherapy-related inflammatory changes (n = 3), or to local neoplastic growth after complete (n = 4) or incomplete (n = 6) resection of the tumor. A metachronous hypopharyngeal cancer developed in 1 group A patient.
LONG-TERM ALIMENTARY COMFORT (STANDARD QUESTIONNAIRE).
Follow-up body weight, as compared with that having existed just after operation, was unchanged or increased in 85.3% of group A patients versus 84.9% of those in group B. Weight variation averaged +4.2% in group A versus +5.8% in group B (p = 0.2271). The number of meals and snacks per day averaged 4.6 in group A versus 4 in group B (p = 0.0275). Ratings given by the patients themselves to their follow-up alimentary comfort averaged 7.6 out of 10 in group A versus 8.8 out of 10 in group B (p < 0.0001). Regarding residual symptoms (Table 1), the only significant difference between the two groups was that sensation of early fullness at or just after meal was more frequent in group A than in group B (p < 0.0001). Prevalence of this sensation decreased with time in both groups (group A, 67.2% at early follow-up versus 52.4% at late follow-up; group B, 47.9% versus 17.8%). A similar phenomenon was recorded for the symptom of diarrhea (combined groups A and B, 68.6% at early follow-up versus 7.4% in the long run). In contrast, cervical heartburn always developed after the second year of follow-up.
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Objective Assessment of the Gastric Transplants
LENGTH OF THE STOMACH.
The cardiopyloric distance in 34 group B patients averaged 22 cm (range, 18 to 24.5 cm) before complete denudation of the lesser curvature and 26.3 cm (range, 23 to 30.5 cm) after this procedure, which made for a gain in length ranging from 10.6% to 38.9% of the initial length.
CAPACITY OF THE STOMACH.
Complete denudation of the lesser curvature increased the gastric capacity from 1,993 mL (range, 1,150 to 2,750 mL) to 2,165 mL on average (range, 1,350 to 2,900 mL). The gain in volume represented 4.9% to 17.4% of the initial volume (mean, 10.4%). In contrast, stapling resection of the lesser curvature reduced the capacity of those denuded stomachs to 1,340 mL on average (range, 800 to 1,950 mL) (Fig 3). So, tubulization reduces the initial volume of the stomach by a range of 21.4% to 47.2% (mean, 32.9%) and that of the denuded stomach by a range of 26.7% to 51.5% (mean, 39.8%).
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). In addition, the blood supply to the fundus mainly came from the vessels located within the wall of the lesser curvature rather than from the vascular arcade of the greater curvature (Fig 5).
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) was significantly less than that of the young healthy volunteers (p < 0.05). In reference to similarly aged control subjects, group A and group B patients studied had a meal capacity of 82% and 93%, respectively, and had an eating rate of 59% (p < 0.05) and 77%, respectively.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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This study also shows that classic technical complications, which are fistulas and stenoses of the cervical anastomosis, are much less frequent and severe (fewer endoscopic dilations required to eliminate stenoses) with the whole stomach than with the gastric tube. The fact that the whole submucosal vascular network is maintained with the former procedure whereas it is interrupted at the staple line with the latter may explain this difference. Arguments that sustain this point of view are the following. First, those technical complications have been shown to be closely related to the poor quality of the blood supply to the fundus [16, 17]. Second, we know from Kudo and associates' study [16] that the parietal blood flow measured by laser Doppler velocimetry is significantly better in the wall of the whole stomach than in that of the gastric tube. Third, the supplemental role of the submucosal vascular network is particularly critical when the ratio of the length of the vascular arcade to that of the greater curvature is low [5, 7] (ie, down to 30% for Levasseur and Couinaud [18] and 46% for us) or when no direct interconnection exists between the right and left gastroepiploic vessels [18, 19]. Fourth, our experience with intraarterial staining of the gastric wall, although limited, confirms the fact already established by Levasseur and Couinaud [18] more than 25 years ago that the submucosal vascular network initially depending on the left gastric vessels represents an important anastomotic pathway between the basal pedicle (ie, the right gastroepiploic vessels) and the top of the fundus. Therefore, after removal of the vascular network of the lesser curvature, as is done with the tubulization procedure, the blood supply to the proposed anastomotic site rests on the minute network located within the uppermost segment of the greater curvature, a condition that predisposes to subacute ischemia and anastomotic complications. This is why resecting the upper part of the greater curvature [5, 18] and maintaining as much submucosal vascular network as possible by placing the staple line close to the free border of the lesser curvature [6] make anatomic sense when constructing a gastric tube. Finally, compression of the transplant in patients having a narrow thoracic inlet [5] may explain why those complications are more frequent with substernal than with mediastinal transplants. In the former instance, resection of the left half of the manubrium and the sternal head of the left clavicle has been recommended [15].
This study also shows that, although both types of gastric transplant provide most of the cancer-free patients satisfactory alimentary comfort in the long run (maintenance or increase of the postoperative body weight in about 85% of them), gastric transplant patients eat more slowly and less than similarly aged control subjects. However, the study provides four arguments that attest to the superiority of the whole stomach over the gastric tube. Compared with gastric tube patients, whole stomach patients take fewer meals and snacks per day, give higher ratings to their long-term alimentary comfort in regard to their condition before suffering from their esophagus, are able to eat more quickly at a test meal, and less often complain of early thoracic or epigastric fullness at meals [10, 11]. Reduction of the gastric capacity by one third on average after tubulization gives a logical explanation to those clinical findings. However, in spite of better expansion of the right side of the stomach after denudation of the lesser curvature (gain in volume, 10.4% on average), sensation of early fullness is still experienced by 17.8% of the whole stomach patients. This may be due to the inability of the whole stomach to expand sufficiently so as to accept a large amount of food when confined into a narrow mediastinum [20]. On the other hand, the fact that the sensation of early fullness at meals is less frequent in the long run than just after operation with both types of gastric transplant suggests that operation-induced inflammatory changes in the gastric wall may temporarily compromise its ability to relax. Finally, deterioration of the alimentary comfort with time such as development of cervical dysphagia often is synonymous with progression of the neoplastic disease.
In conclusion, the whole stomach whose lesser curvature is denuded is less exposed to the risk of cervical complication and provides better alimentary comfort than does the gastric tube because the whole submucosal vascular network is maintained and the gastric capacity is increased slightly. The main contraindication of use of the whole stomach is a tumor located just proximal to the cardia, a condition that requires resection of both lesser curvature and the subcardial area to obtain a cancer-free gastric margin.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Collard, Digestive Surgery Unit, St-Luc Academic Hospital, Hippocrate Avenue, 10, B-1200 Brussels, Belgium.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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