A Study On Clinical Application Of Jejunal Interposition After Radical Proximal Gastrectomy

Objective:The gastric cancer is the most common malignant tumors in the digestive system.At present,the mortality of the gastric cancer is the second in all of tumors worldwide and the first place of malignant tumors in our country. Mechanism for the occurrence and development of gastric cancer is not clear so far.Growth and differentiation of gastric cancer control by many factors.Gastric cancer cell proliferation and metastasis are closely related to gastrointestinal hormone. Gastrointestinal hormone mainly divided into tumor-associated power-associated.Tumor-associated hormones are divided into the promotive and inhibitive type.Promotive hormones including gastrin(Gas),cholecystokinin(CCK),bombesin (BOM),epidermal growth factor(EGF),epidermal growth factor(IGF) et al.Inhibitive hormones including somatostatin (SS) et al.Power-associated hormones are divided into excitatory and inhibitory hormone.Excitatory gastrointestinal hormones including motilin(MTL),Gas.Inhibitory gastrointestinal hormones including CCK,SS and et al. Different digestive tract reconstruction on the study on the impact of gastrointestinal hormones are less.In recent years the proximal gastric cancer increased obviously in the proportion of gastric cancer.Many surgeons are used to esophagogastrectomy because of easy operation and short operating duration. However,it inevitably led to high incidence of reflux esophagitis.Patients need after long-term semi-supine sleep and taking anti-reflux drugs.Not only increased the financial burden on patients,but also seriously affect their quality of life.Thus an new method of reconstruction to improve the quality of life in patients is urgent need.This experiment with traditional esophagogastrectomy as controls,jejunal interposition (discontinuous,consecutiv) is used after radical proximal gastrectomy.Postoperative operating duration,serum nutritional parameters,body weight,prognostic nutritional index(PNI), and gastrointestinal hormone(Gas,CCK,SS,MTL) and quality of life were compared between three groups.To explore the ideal method of digestive tract reconstruction after radical proximal gastrectomy and the impact to gastrointestinal hormones of operation.Methods:From 2004-1 to 2008-7,98 patients who had undergone radical proximal gastrectomy jejunal interposition for gastric carcinoma were allocated into 2 groups randomly, including jejunal interpositionⅠ(discontinuous) 77 cases as group A and jejunal interpositionⅡ(consecutive) 21 cases as group B and also with 30 patients undergone esophagogastrectomy as controls.The operating duration and serum nutritional parameters,including hemoglobin(Hb), albumin(ALB) and total protein(TP),body weight,prognostic nutritional index(PNI),and gastrointestinal hormone(Gas, CCK,SS,MTL) were investigated preoperation,7 days after operation and 6 months after operation.Hb was determined by automatic blood cell.TP,ALB were measured by automatic biochemical analyzer.PNI=10×ALB(ALB:g/dl)+0.005×total lymphocyte count(/mm3).Gastrointestinal hormones were used to detect the use of radioimm.All cases were followed up 12 months after operation.The quality of life was evaluated by grading standard for reflux esophagitis(Visick grade).Visick grade:VisickⅠclass for asymptomatic,VisickⅡclass for occasional symptoms,VisickⅢclass can be tolerated for the symptoms,VisickⅣclass for the symptoms can not be tolerated.All statistical analyses were carried out with SPSS 12.0 and P<0.05 were considered significant.Results:1 Operating durationThe operating duration of group A was 210±53 minutes (the operating duration of digestive tract reconstruction was 50±18 minutes).The operating duration of group B was 201±45 minutes(the operating duration of digestive tract reconstruction was 44±20 minutes) and control group was 150±75 minutes. The operating duration of group A and B were slightly longer than group C.The operating duration of group A and B were no significant difference.2 Serum nutritional parameters,body weight and PNI 2.1 Comparison with group A and CGroup A:the values of Hb,ALB,TP 7 days after operation were lower than those preoperation significantly(P<0.05); There were no significant differences between those six months after operation and those preoperative(P>0.05).The values of HB,ALB,TP six months after operation returned to the preoperative levels.PNI six months after operation were higer than preoperative level,but body weight return to the preoperative levels.Group C:The values of Hb,ALB,TP 7 days after operation were lower than those of preoperative significantly(P<0.05); The values of Hb 6 months after operation were lower than that preoperation significantly(P<0.05);There were no significant differences between the values of ALB,TP 6 months after operation and those of preoperation(P>0.05).The values of Hb 6 months after operation did not return to the preoperative levels. PNI 6 months after operation return to the preoperative level, but body weight is still significantly lower than preoperative levels.The values of HB 6 months after operation in group A were higher than those in group C(P<0.05);The values of HB 6 months after operation in group A return to the preoperative levels,while those in group C did not return to preoperative levels.PNI and body weight six months after operation in group A were higher than those in group C significantly(P<0.05).2.2 Comparison with group B and C Group B:the values of Hb,ALB,TP 7 days after operation were lower than those preoperation significantly(P<0.05). There were no significant differences between those 6 months after operation and those preoperative(P>0.05).The values of HB,ALB,TP 6 months after operation returned to the preoperative levels.PNI 6 months after operation were higer than preoperative levels,but body weight return to the preoperative levels.The values of HB 6 months after operation in group B were higher than those in group C(P<0.05).The values of HB 6 months after operation in group B return to the preoperative levels,while those in group C did not return to preoperative levels.PNI and body weight six months after operation in group B were higher than those in group C significantly(P<0.05).2.3 Comparison with group A and BThere were no significant differences of HB,ALB,TP,body weight and PNI in the two groups(P>0.05).The values of Hb, ALB,TP 7 days after operation were lower than those of preoperation significantly(P<0.05).There were no significant differences between those of 6 months after operation and those of preoperation(P>0.05).The values of HB,ALB,TP 6 months after operation return to the preoperative levels.PNI 6 months after operation were higer than preoperative levels,but body weight return to the preoperative levels.3 Gastrointestinal hormone3.1 Comparison with group A and C:There were no significant differences about values of Gas,CCK,SS,MTL in preoperative, 7 days after operation and 6 months after operation(P>0.05).3.2 Comparison with group B and C:There were no significant differences about values of Gas,CCK,SS,MTL in preoperative, 7 days after operation and 6 months after operation(P >0.05).3.3 Comparison with group A and B:There were no significant differences about values of Gas,CCK,SS,MTL in preoperative, 7 days after operation and 6 months after operation(P>0.05).There were no significant differences about values of Gas, SS,MTL,CCK in different periods of Surgery of group A,B,C. However gastrointestinal hormones in the different periods of surgery had the following changes:(1) Gas:the values of Gas preoperation,7 days after operation and 6 months after operation decreased progressively;The values of Gas 6 months after operation are lower than those preoperative levels significantly(P<0.05).(2) CCK:the values of CCK preoperative,7 days after operation and 6 months after operation increased progressively;The values of CCK 6 months after operations are higher than those preoperative levels significantly(P<0.05).(3) SS:the values of SS preoperative,7 days after operation and 6 months after operation decreased progressively;The values of SS 7 days after operation and 6 months after operations are lower than those preoperative levels significantly(P<0.05).(4) MTL:The values of MTL preoperative,7 days after operation and 6 months after operation increased progressively;The values of MTL 7 days after operation and 6 months after operations are higher than those preoperative levels significantly(P<0.05).4 Quality of lifeFollowing-up one year after operation,Visick index of patients in A almost was in the classⅠ-Ⅱ.Only 7 cases appeared mild refluxing symptoms.Visick index of patients in A almost was in the classⅠ-Ⅱ.Only 1 case appeared mild reflux symptoms.Visick index of patients in C was 76.67%in the classⅠ-Ⅱ.And most of them depending on drug to relieve the symptom of refluxing.There were significant differences between group A and C(P=0.000,P<0.05).There were significant differences between group A and C(P=0.000, P<0.05).There were no significant differences between group A and B(P=0.847,P>0.05).The quality of life of patients in JI were higher than in control group.Conclusion:1 Comparison with group JI and esophagogastrectomy:the operating duration of JI relatively extended.But using three staplers in the course of digestive tract reconstruction can speed up the process of surgery,while anastomotic stenosis and obstruction,anastomotic leakage had been no increase in complications.At the same time,the use of domestically produced stapler,stitching instrument and reusable stapler greatly reduce the financial burden of patients.The serum nutritional parameters,body weight and PNI of patients after JI rapidly restored and the quality of life in JI were better than the esophagogastrectomy.There were no differences between the impact on gastrointestinal hormones(Gas,CCK,SS,MTL) in JI and esophagogastrectomy.2 The difference between JIⅠandⅡis whether to maintain the continuity of original the jejunum.There were no differences in operating duration,serum nutritional parameters, body weight and PNI,gastrointestinal hormones(Gas,CCK,SS, MTL) and quality of life in JIⅠandⅡ.3 There were no differences in gastrointestinal hormones(Gas, CCK,SS,MTL) after the three surgery in preoperation,7 days after operation and 6 months after operation.And the dynamic changes of gastrointestinal hormones in the radical proximal gastrectomy of the periods show that:Gas,CCK,SS detection may help to make the diagnosis of gastric cancer prognosis and monitor the prognosis.MTL can be used as an indicator of gastric motility.The JI is an ideal procedure digestive tract reconstruction to prevent the incidence of reflux esophagitis after proximal gastrectomy,to construct a gastric reservoir,to maintain the physiological tract,to recover weight and nutrition and improve quality of life quickly.Tumor-associated hormone(Gas,CCK, SS) detection may help to make the diagnosis of gastric cancer prognosis and monitor the prognosis.MTL can be used as an indicator of gastric motility.The JI is an ideal procedure digestive tract reconstruction after radical proximal gastrectomy.