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Prof. G. de Manzoni

University of Verona Department of Surgery Division of Upper G.I. Surgery Prof. G. de Manzoni. “ Recenti acquisizioni fisiopatologiche post chirurgia digestiva maggiore ” STOMACO. Prof. G. de Manzoni. Bari, November 8th. Gastric Phy siology. Allow : bolous transit

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Prof. G. de Manzoni

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  1. University of Verona Department of Surgery Division of Upper G.I. Surgery Prof. G. de Manzoni “Recentiacquisizionifisiopatologiche post chirurgiadigestivamaggiore” STOMACO Prof. G. de Manzoni Bari, November 8th

  2. Gastric Physiology Allow: • bolous transit • Mix of the bolous Avoid: • acid reflux • biliary reflux • quick passage in the duodenum His Angle LES Pacemaker region Pyloric sphincter

  3. Gastric Physiology Parietal cells HCl production Mucus cells Protection

  4. Gastric Physiology Vagus nerve • Motility • Secretions Celiac plexus

  5. Gastric Pathology V Main Cancer Peptic Ulcer Cancer of gastric stump Obesity

  6. Surgical goals Resection Reconstruction • Resection margins (T0) • Nodal dissection (N0) • Acid-Biliary reflux • Good emptying • Number of meals • Body weight • QOL

  7. Surgical goals The importance of QOL… Surgery alone: 23% CTgroup: 36% 5y OS for advanced gastric cancer Cunningham D, et al. (2006) N Engl J Med

  8. Surgical goals “cutting less does not always lead to better results…”

  9. Gastric resections Total Gastrectomy JGCA (2011) Gastric Cancer

  10. Gastric resections Distal Gastrectomy • Distal gastric tumors • ≥ 3 or 5 cm proximal margin (according to growth pattern) JGCA (2011) Gastric Cancer

  11. Gastric resections Pylorus Preserving • Middle gastric tumors • ≥ 4 cm from pylorus JGCA (2011) Gastric Cancer

  12. Gastric resections Proximal Gastrectomy • Proximal tumors • ≥ ½ distal stomach preserved JGCA (2011) Gastric Cancer

  13. Gastric reconstructions Total Gastrectomy Longmire interposition Roux-en-Y • Less biliary reflux • Preservation of physiological route • Improved absorption • Reduced weight loss

  14. Gastric reconstructions Total Gastrectomy • Review of 9 RCT (1985-2009) • Roux-en-Y VS Longmire interposition No Differences Esophagitis Body weight QOL Mariette, et al.(2010) J ViscSurg

  15. Gastric reconstructions Total Gastrectomy • Multicenter RCT (105 pz) • Roux-en-Y VS Longmire interposition QOL No Differences Ishigami, et al.(2011) Am J Surg

  16. Gastric reconstructions Pouch or not? Principles: • Increase food intake at each meal • Prevent dumping syndrome • Prevent reflux esophagitis (?) Better QOL?

  17. Gastric reconstructions Pouch or not? • 9 RCT Roux-en-Y (474 pz) Pouch is better in… Body weight Long term better QOL… Eating capability Dumping syndrome Gertler, et al.(2009) Am J Gastroenterol

  18. Gastric reconstructions Total Gastrectomy… In Japan 95% Roux-en-Y reconstruction • 145 Japanese institutions • 138 use Roux-en-Y reconstruction • 26 institutions performs Pouch Kumagai, et al.(2012) Surg Today

  19. Gastric reconstructions Distal Gastrectomy Billroth II (+ Braun) Billroth I Roux-en-Y • Restore physiologic path • Always possible without tension • Less biliary reflux Mariette, et al. (2010) J ViscSurg

  20. Gastric reconstructions Distal Gastrectomy VS Billroth II Roux-en-Y • 75 pz (mean fu 182-193 months) • Surgery for peptic ulcer Less reflux for Roux in long term follow-up Csendes, et al. (2009) Ann Surg

  21. Gastric reconstructions Distal Gastrectomy VS Billroth II + Braun Roux-en-Y • 159 pz (12 months fu) • Prospective randomized trial Endoscopic findings Hepatobiliary scan Biliary reflux 3.7% Roux vs 75% BII Lee, et al. (2012) Surg Endosc

  22. Gastric reconstructions Distal Gastrectomy Billroth II (+ Braun) Billroth I Roux-en-Y • High biliary reflux

  23. Gastric reconstructions Distal Gastrectomy VS Roux-en-Y Billroth I Better for Roux • Esophagitis • Gastritis • Food residue • Bile reflux P<0.05 Inokuchi, et al. (2012) Gastric Cancer Sano, et al. (2007) Int J ClinOncol Endoscopic findings

  24. Gastric reconstructions Distal Gastrectomy VS Roux-en-Y Billroth I • 159 pz (12 months fu) • Prospective randomized trial Biliary Reflux Billroth I 56.3% Roux 3.7% Hepatobiliary scan Lee, et al. (2012) Surg Endosc

  25. Gastric reconstructions Distal Gastrectomy VS Roux-en-Y Billroth I • 268 pz (21 months median fu) • Multicenter randomized phase II NO differences in QOL EORTC QLQ-C30 Takiguchi, et al. (2012) Gastric Cancer

  26. Gastric reconstructions Distal Gastrectomy Billroth I Roux-en-Y but • High biliary reflux • High gastritit • High esophagitis • High food residue NO differences in QOL…

  27. Gastric reconstructions Roux-en-Y • Roux stasis syndrome • Difficult endoscopic management of bile ducts • Less biliary reflux • Less gastritis • Less esophagitis • Less food residue

  28. Gastric reconstructions Distal Gastrectomy… In Japan 77% B1 21% Roux • 145 Japanese institutions • 112 (77%) use B1 reconstruction as first choice • 30 (21%) use Roux reconstruction as first choice Kumagai, et al.(2012) Surg Today

  29. Gastric reconstructions Pylorus Preserving Billroth I Pros • Less dumping syndrome • Less gastritis • Less reflux esophagitis • Less gallbladder stones Evolution Cons • More delayed gastric emptying • (Limited oncological dissection)

  30. Gastric reconstructions Preservation of hepatich and pyloricbranchs Preservation of coeliach branch Preservation of infrapyloric vessels • 611 pz (50 months median fu) Morita,et al.(2008) Br J Surg

  31. Gastric reconstructions Pylorus Preserving • 39pz(40 months mean fu) • Pylorus preserving VS Billroth I Better Symptom score But… Delayed Gastric emptying for solids Scintigraphic system Park,et al.(2008) World J Surg

  32. Gastric reconstructions Proximal Gastrectomy Pros Cons Theoreticallybetter for earlystagesproximalcancer and Siewert III because of better QOL… Anastomotic stricture Reflux esophagitis Improved nutrition

  33. Gastric reconstructions Proximal Gastrectomy • 131 pz • Endoscopic evaluation forstenosis • Modified Visick score for GERD Laparoscopy assisted proximal gastrectomyVS total gastrectomy High GERD High Stenosis Kim,et al.(2012) Gastric Cancer

  34. Gastric reconstructions Proximal Gastrectomy No advantages for PG instead of TG… Same nutritional status Kim,et al.(2012) Gastric Cancer

  35. Our experience (2000-2010) 50 pz Siewert II 24 pz Siewert III 26 pz • Short gastric conduit reconstruction • T-T mediastinal anastomosis

  36. Our experience (2000-2010) Endoscopic diagnosis

  37. Cardias adenocarcinoma Siewert II Siewert I Siewert III Total gastrectomy Total gastrectomy Ivor Lewis Proximal gastrectomy Ivor Lewis

  38. Ivor Lewis – Personal Tecnique • Narrow gastric conduit • Intramediastinical conduit position • GERD reduction

  39. Better vascularization • Avoids the “could de sac” • Without weaknesses Termino-Terminal Anastomosis

  40. Eases the venous outflow • Less tension on the anastomosis • Over-azygos for GERD reduction • Shorter conduit with better vascularization Prefer intrathoracic anastomosis

  41. Our experience until 2010 • Ivor Lewis • EAC + SCC • PPI for 12 months post-op

  42. QOL questionnaire • Good reliability • Good responsiveness • Good praticality (2 minutes) Velanovich,et al.(2007) Dis Esophagus

  43. ...2011 results • Ivor Lewis • EAC + SCC • PPI for 12 months post-op

  44. Prophylactic Cholecistectomy? Rationale • Higher risk of gallstones formation • Vagal denervation • Postoperative fasting • Extent of lymphadenectomy • Extent of gastric resection • Digestive reconstruction • Difficult endoscopic management (Roux-en-Y) • Higher morbi-mortality for subsequent cholecistectomy

  45. Physiophatology Alteration in hormons production: cholecystokinin and secretin hepatich branch of vagus nerve Altered motility Altered motility Altered secretions

  46. Cholelythiasis …5 y after gastric surgery In general population 10% 15-25% develop cholelythiasis Symptomatic in 30%

  47. 16 studies (retrospective and prospective) • 3735 pz CCE: cholecistectomy Low additional morbidity for the whole cohort High morbidity in delayed CCE Gillen,et al.(2010) World JSurg

  48. 16 studies (retrospective and prospective) • 3735 pz Simultaneouscholecystectomy seemsnot to be necessary Gillen,et al.(2010) World JSurg

  49. RCT – end of recruitment analysis • Propylactic cholecystectomy (PC) VS standard surgery (SS) • Roux-en-Y and Billroth II Perioperative complications Biliary: PC 1.5% vs SS 0% N.S. 1 pz: Bile from drainage:Conservative management (desappear in a few days) Overall: PC 25% vs SS 17% N.S. Bernini,et al.(2012) Gastric Cancer

  50. Prophylactic cholecystectomy Extended lymphadenectomy (D2-D3) Total Gastrectomy PC Early stage (long survivor) Giacopuzzi S, de Manzoni G…Cordiano C,et al.(2008) Biliary Lithiasis

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