Table Of ContentGastric Substitutes
J.
METZGER· F. HARDER· M. VON FLUE
Springer-Verlag Berlin Heidelberg GmbH
J.
METZGER
F. HARDER
M. VON FLÜE
Gast ic
S stet tes
With 119 figures, mostly in color,
and 34 tables
, Springer
Dr. med. J. METZGER ISBN 978-3-642-62497-1
Leitender Arzt
Kantonsspital Luzem Cataloging-in-Publication Data applied for
Chirurgische Klinik A
Die Deutsche Bibliothek -CIP-Einheitsaufnahme
6000 Luzem, Switzerland
Metzger, Jürg: Gastric substitutes 1 Jürg Metzger; Felix
Prof. Dr. med. F. HARDER Harder; Markus von Flüe. -
Netzibodenstrasse 34 Springer-Verlag Berlin Heidelberg GmbH, 2002
ISBN 978-3-642-62497-1 ISBN 978-3-642-55880-1 (eBook)
4133 Pratteln, Switzerland
DOI 10.1007/978-3-642-55880-1
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Contents
1 Introduction ............. . 1
2 The Consequences of a Gastrectomy 3
2.1 The Physiology of the Stomach .... 3
2.2 Postgastrectomy Syndromes: An Overview 4
2.3 Disturbed Gastric Function and Motility 5
2.4 Reduced Reservoir Problems
(Small Gastric Remnant) .. 5
2.5 The Loss of Duodenal Route . 5
2.6 Dumping Symptoms ..... 6
2.6.1 Incidence and Pathophysiology 6
2.6.2 Early Dumping ......... . 6
2.6.3 Late Dumping . . . . . . . . . . . . 6
2.6.4 A Classification and Scoring System 6
2.6.5 Therapy ..... 7
2.7 Alkaline Reflux 7
2.7.1 Pathophysiology 7
2.7.2 Diagnosis .... 8
2.7.3 Barrett's Oesophagus and Oesophageal Cancer 8
2.7.4 Treatment and Prevention . . 9
2.8 Loop Syndromes ...... . 11
2.8.1 The Afferent Loop Syndrome 11
2.8.2 The Efferent Loop Syndrome 11
2.9 The Roux-Stasis Syndrome 11
2.10 Postvagotomy Diarrhoea . . . 12
2.11 Operations to Replace the Missing Pylorus 12
2.12 Quality ofLife 13
2.12.1 Significance 13
2.12.2 Tools 13
References 16
VI Contents
3 Gastric Substitutes: An Overview 25
3.1 History ...... . 25
3.1.1 Pouches ..... . 25
3.1.2 Duodenal Passage 28
3.1.3 Antireflux Procedures 30
3.1.4 Large-Bowel Procedures 30
3.2 Roux-en-Y Reconstruction 30
3.3 Operative Techniques ... 31
3.3.1 Small-Bowel Substitutes .. 32
3.3.1.1 The Hunt-Lawrence-Rodino Pouch 32
3.3.1.2 The Longmire Interpositional Pouch 32
3.3.1.3 Oesophagojejunoplication (Siewert -Peiper-Pouch) 32
3.3.1.4 Cuschieri Jejunal Pouch 33
3.3.2 Large-Bowel Substitutes 33
3.3.2.1 The Ileocaecal Segment 33
3.3.2.2 Transverse Colon . . . . 34
3.3.2.3 The Left Colon Substitute with the Creation
of a His Angle as Reflux Barrier . . . . . 34
3.4 The Reservoir: A Necessity? ...... . 34
3.4.1 Evidence Supporting the Use of Pouches 34
3.4.2 Against the Use of Pouches .... . 39
3.4.3 Experimental Work ........ . 39
3.5 The Benefits of a Duodenal Passage . 40
3.5.1 Retaining the Duodenal Route 40
3.5.2 Disadvantages of Preserving the Duodenal Route 41
3.5.3 Experimental Work ......... . 42
3.6 The Consequences of Alkaline Reflux 42
3.7 Pouches, the Duodenal Route
and Antireflux Procedures 43
3.8 State of the Art in 2001 43
3.9 Summary ........ . 44
3.10 Conclusion 45
3.11 The Ideal Gastric Substitute 45
References 45
4 The lIeutaecal Segment .............. 53
........
4.1 Surgical Anatomy . . . . . 53
4.2 Histology ......... . . . . . . . . 54
4.3 The Physiology of the Ileocaecal Region 55
4.3.1 Motility and Pressure Zones Which Suggest
That There Is a Physiological Sphincter 55
4.3.2 Mechanical Barrier ..... 56
4.3.3 Regulation of the Sphincter 58
4.3.3.1 Food and Filling ....... 58
Contents VII
4.3.3.2 Hormones .... . 59
4.3.3.3 Nerve Supply .. . 59
4.3.3.4 Neurotransmitters 59
4.3.3.5 Chemicals and Drugs 59
4.3.3.6 The Ileal Brake ... 59
4.4 Loss of the Ileocaecal Valve 60
4.4.1 The Consequences of Ileocaecal Resection 60
4.4.2 Replacement of the Ileocaecal Valve 60
4.5 Summary 61
References 61
5 lIeocaecallnterpositional Graft
as a Gastric Su bstitute .. ... 67
5.1 Management of Gastric Cancer ....... . 67
5.1.1 Extent of Gastric Resection ......... . 67
5.1.2 Lymphadenectomy (Dl vs D2 Compartment) 68
5.2 The History of the Ileocaecal Segment
as a Gastric Substitute 68
5.3 Multipurpose Substitute 71
5.3.1 Bladder Replacement . . . 71
5.3.2 Oesophagus Replacement 72
5.3.3 Biliary Drainage 73
5.3.4 Rectal Replacement . 73
5.4 The Patients . . . . . 75
5.5 Protocol ....... . 76
5.5.1 The Preoperative Assessment 76
5.5.2 Evaluation: The Follow-Up 76
5.5.2.1 Body Weight ...... . 76
5.5.2.2 Endoscopy ......... . 76
5.5.2.3 Interview: Questionnaires 76
5.5.2.3.1 Dumping and Reflux Symptoms 76
5.5.2.3.2 The Quality-of-Life Score ..... 77
5.5.2.3.3 The Eypasch Scoring System:
The Gastrointestinal Quality-of-Life Index Score
(GIQLI) ................. . 77
5.5.2.4 Additional Tests (Special Evaluations) 79
5.5.2.4.1 Gastric Emptying ..... . 79
5.5.2.4.2 The Glucose Tolerance Test 79
5.5.2.4.3 Manometry ........ . 79
5.5.2.5 Data Analysis ... . 80
5.5.3 Statistical Analysis 80
5.6 Operative Technique 80
5.6.1 Position ....... . 80
5.6.2 Incision ....... . 80
5.6.3 Exploration and Determination of Operability 81
VIII Contents
5.7 Total Gastrectomy and Lymphadenectomy 82
5.7.1 Subdiaphragmatic Reconstruction 82
5.7.2 Oesophagoileal Anastomosis 84
5.7.3 Colo duodenal Anastomosis 86
5.7.4 Ileotransversostomy ..... 88
5.7.5 Intrathoracic reconstruction 89
5.8 Results ............ . 90
5.8.1 Operation Data ....... . 90
5.8.2 Complications and Patients Lost to Follow-Up 90
5.8.3 Body Weight Development ........ . 92
5.8.4 Diarrhoea, Dumping and Reflux Symptoms 92
5.8.5 Quality-of-Life Score 93
5.8.6 Endoscopy and Biopsy 93
5.8.7 Special Examinations . . 93
5.8.7.1 Gastric Emptying Rates 93
5.8.7.2 Glucose Tolerance Test 94
5.8.7.3 Manometry ...... . 94
5.9 Discussion . . . . . . . . 94
5.9.1 The Advantages of the Ileocaecal Segment
as a Gastric Substitute ......... . 94
5.9.2 A Comparison of the Ileocaecal Segment
with Other Reconstructions ...... . 96
5.9.2.1 Comparison with Small-Bowel Substitutes 96
5.9.2.l.l Morbidity and Mortality . . . . . . . . . . 96
5.9.2.1.2 Postoperative Body Weight Development 97
5.9.2.1.3 Dumping, Gastric Emptying Rates
and Glucose Tolerance 97
5.9.2.1.4 Alkaline Reflux 98
5.9.2.1.5 Manometry ..... . 99
5.9.2.1.6 Quality ofLife . . . . . 99
5.9.2.2 Comparison with Large-Bowel Substitutes 99
5.9.3 Comparing Our Results With Other Authors
Who Used the Same Segment ...... . 99
5.9.4 Conclusions from the Literature .... . 102
5.9.5 The Ileocaecal Segment as a Replacement
for the Oesophagus and Stomach . . . . . 102
5.9.6 The Consequences of an Ileocaecal Transposition
on Gut Transit 102
5.10 Indications 103
5.11 Outlook 103
References ..... . 103
lIeo(olon Segment as p,lorus Replacement . . . . . 111
6.1 Analysis 111
6.2 Model . 112
6.2.1 Animals 112
Contents IX
6.2.1.1 Anatomy ...... . 113
6.2.1.2 Physiology . . . . . . 114
6.2.1.3 Feeding and Housing 114
6.2.1.4 Training ..... . 114
6.2.2 Protocol ...... . 115
6.2.2.1 Aims of the Study . . 116
6.2.2.2 Outcome Measurements 116
6.2.3 Statistical Analysis ... 117
6.2.4 Body Weight and Postoperative Course 117
6.2.5 Glucose Tolerance Test ........ . 117
6.2.6 Gastroscopy and Biopsy . . . . . . . . . 117
6.2.7 Scintigraphic Measurement of Gastric Transit 118
6.2.8 Postmortem: Blood Samples, Histology,
Immunohistology, Gastric Specimen Measurements 119
6.3 Technique .... . 121
6.3.1 Anaesthesia ... . 121
6.3.2 Surgical Technique 122
6.3.2.1 Resection ..... 122
6.3.2.2 Roux-en-Y Reconstruction 122
6.3.2.3 Ileocolon Interpositional Graft 123
6.3.3 Postoperative Care .. 125
6.4 Results ............. . 126
6.4.1 Operative Procedures
and Intraoperative Complications 126
6.4.2 Postoperative Course . . 126
6.4.3 Body Weight ..... . 127
6.4.4 Glucose Tolerance Test 127
6.4.5 Rx Contrast Study and Gastric Emptying 129
6.4.6 Endoscopy and Histology After 3 Months 132
6.4.7 Postmortem: Blood Samples, Histology,
Immunohistology, Gastric Specimen Measurements 134
6.5 Discussion and Indications 136
6.5.1 Indications for the Procedure 139
6.6 Summary 139
6.7 Conclusion 139
References 140
Subject Index . ......................... 145
-
Acknowledgements
I express my gratitude to everyone supporting my research activity.
Special thanks are due to Dr. Lukas Degen MD (Oberarzt, Depart
ment of Gastroenterology, University of Basel), who gave me out
standing support and participated in the experimental part of my
studies. He was of great help in developing and performing the
model for scintigraphic measurement of gastric emptying rates in
G6ttingen minipigs.
Thanks are due to Professor Felix Harder MD (chairman of the
Department of Surgery, University of Basel), Professor Michael He
berer MD (head of the Research Division, Department of Surgery,
University of Basel) and Professor Markus von Flue (chairman of
the Department of Surgery, Kantonsspital Luzern) who collaborated
in research. Markus von Flue initiated the idea of using the ileocae
cal segment as a gastric substitute after partial or total gastrectomy.
Many thanks are also due to Richard Weilenmann (Dr. vet., head
of the Veterinary Unit, Roche Basel) and his team, who supported
the practical part of my studies on G6ttingen minipigs.
I wish to thank all the scrub nurses (organiser, Frau Marianne
Settelen) and anaesthetists (Martin Siegemund and Wolfgang Stu
der) who were part of the animal operating theatre team.
I am especially grateful for my family's continuous support and
understanding.
Many thanks are also expressed to Tony Amery FRCS who care
fully revised the manuscript.
My work and my experiments were supported by grants from the
Swiss National Science Foundation.
