Gastric substitute after total gastrectomy--clinical relevance for reconstruction techniques.

BACKGROUND: More than 60 different methods of reconstruction after total gastrectomy have been described. The different surgical procedures can be reduced essentially to pouch reconstruction, pouch size and maintenance of duodenal passage.
METHODS: To clarify the importance of pouch reconstruction and maintenance of duodenal passage, we reviewed all controlled prospectively randomized clinical studies reporting on the various methods of reconstruction after gastrectomy.
RESULTS: After reconstruction with a pouch, 6-month postoperative patients have a better food intake, a slower food passage (t50% 12 vs 25 min), fewer postprandial symptoms (4-10% vs 20-60%), less weight loss (7 vs 14 kg), and in tendency, they have a better quality of life. With maintenance of duodenal passage, disturbance of blood sugar regulation (stimulated glucose level 22% lower) and iron deficiency anemia (hemoglobin: 13.9 vs 12.5 g/dl; iron: 18.4 vs 10.2 micromol/l) are prevented. In addition, the patients lose less body weight (8% higher) and they tend to have a better quality of life (life quality score: 84 vs 76 points). Nevertheless, in several studies the number of patients is too small to demonstrate significant differences.
CONCLUSIONS: After total gastrectomy, curatively operated patients might benefit from a reconstruction with pouch and maintenance of duodenal passage. Nevertheless, the present study results are partially divergent. For definitive demonstration of the superiority of this technique, further controlled longitudinal studies should be conducted with a larger number of cases and suitable instruments for assessing the quality of life.