What Is the Difference between Proximal and Total Gastrectomy Regarding Postoperative Bile Reflux into the Oesophagus?

Abstract

Background: Tumours of the oesophagogastric junction and the gastric cardia can be treated either with proximal or with total gastrectomy. Reflux of bile and other duodenal contents into the oesophagus following proximal gastrectomy has generally been considered worse than reflux after total gastrectomy. The aim of the present study was to test this assumption given that there is limited literature regarding objective evaluation of the postoperative duodeno-oesophageal reflux. Patients and Methods: We carried out bilirubin monitoring with the ambulatory spectrophotometer Bilitec 2000 in two groups of patients and in one group of healthy volunteers matched in age and sex. The proximal gastrectomy group consisted of 8 patients who underwent proximal gastrectomy and an end-to-side oesophagogastrostomy without pyloric drainage procedure. The total gastrectomy group consisted of 11 patients who underwent total gastrectomy and Roux-en-Y reconstruction with a 50-cm-long jejunal limb. The control group consisted of 8 healthy volunteers. In all cases, an absorption value of 0.14 was used as the threshold for reflux episodes. Results: The median fraction of time that bilirubin absorbance was >0.14 in the proximal versus total gastrectomy group was 47.4 and 13.4%, respectively (p = 0.02). The difference between the two groups was significant in the supine position (p = 0.03), whilst the upright position, meal and postprandial periods were not found to have significant difference. Likewise, no significant difference was found in the number of reflux episodes. The median fraction of time in the proximal gastrectomy group compared with controls was 47.4 versus 3.95% (p < 0.001), whilst in the total gastrectomy group compared with controls, itwas 13.4 versus 3.95% (p > 0.05). The number of reflux episodes in the proximal gastrectomy group compared with controls was 74 versus 21 (p = 0.02), whilst in the total gastrectomy group compared with controls, it was 103 versus 21 (p > 0.05). Conclusions: Total gastrectomy with Roux-en-Y reconstruction reduces the time of oesophageal exposure to duodenal juices as compared with proximal gastrectomy. This effect seems to be more prominent in the supine position.

Comparative study of clinical outcomes between laparoscopy-assisted proximal gastrectomy (LAPG) and laparoscopy-assisted total gastrectomy (LATG) for proximal gastric cancer

“…Modification through esophagogastrostomy after proximal gastrectomy to date has shown disappointing results in the rates of reflux symptoms and anastomotic stricture [10]. Katsoulis and colleagues [19] reported that 100 % of patients experienced reflux symptoms after proximal gastrectomy, and Kim and associates [18] also reported high rates of reflux esophagitis (48 %). Esophagogastrostomy with antireflux procedures could be an acceptable approach if the surgeon has sufficient experience in proximal gastrectomy.…”

Technical feasibility and safety of laparoscopy‐assisted total gastrectomy in gastric cancer: A comparative study with laparoscopy‐assisted distal gastrectomy

“…However, other authors have suggested that total gastrectomy is a better choice for upper gastric cancer because of the likelihoods of reflux esophagitis and no improvement in quality of life after proximal gastrectomy [29,30]. At our institution, only total gastrectomy is performing for upper gastrectomy because of the limitations of proximal gastrectomy, which is the reason for different distal margins in LATG and LADG.…”

Laparoscopy-assisted resection of proximal gastric cancer: is less than all more or less complete, or is all more, nonetheless?

“…There is clearly a greater risk of reflux after a distal stomach-preserving resection as observed after LAPG, and the predominantly bile reflux-related challenges have been described by others [6,10]. Severity and frequency of reflux appears to be related to the reconstruction rather than the type of resection [11].…”