Novel Operative Technique for Vagal Nerve- and Pyloric Sphincter-preserving Distal Gastrectomy Reconstructed by Interposition of a 5 cm Jejunal J Pouch with a 3 cm Jejunal Conduit for Early Gastric Cancer and Postoperative Quality of Life 5 Years after Operation

The importance of the vagal nerve and pyloric sphincter, the need for pouch reconstruction, and the ideal pouch volume are all matters of controversy. A novel operative technique for vagal nerve- and pyloric sphincter-preserving distal gastrectomy reconstructed by interposition of a 5 cm jejunal J pouch with a 3 cm jejunal conduit was developed as a function-preserving surgical technique to prevent postgastrectomy disorders. The application criteria and technique are outlined in this article. Postoperative quality of life was also investigated clinically. Twenty subjects who underwent this surgical operation (group A: 16 men and 4 women aged 41 to 70 years, mean age 59.5 years) were interviewed to inquire about postoperative gastrointestinal symptoms. These patients were compared with 44 others who underwent conventional distal gastrectomy with D2 lymphadenectomy (group B: 30 men and 14 women aged 43 to 73 years, mean age 62.6 years). Included were patients with early cancer [mucosal or submucosal 1 (SM1) cancer and no lymph node metastasis (N0)] in the middle or lower third of stomach (or both) who were either not eligible for endoscopic excision of gastric mucosa or for partial gastric excision in the mucosa = 3.5 cm or SM1 5.5 cm, or further in distance from the anal margin of the cancer to the pyloric sphincter. Cases in which the remnant stomach would become one-third or less of the original size were also applied. During excision with lymph nodes, the hepatic and celiac branches bifurcating from the anterior and posterior trunks of the vagal nerve were preserved. The antrum was severed 1.5 cm from the pyloric sphincter, preserving the arteria supraduodenalis. The substitute stomach was created as a 5 cm jejunal pouch with a 3 cm jejunal conduit for orthodromic peristaltic movement using an automatic suture instrument to complete a side-to-side anastomosis of the folded jejunum. The anal side of the gastric remnant was manually anastomosed with the jejunal J pouch, and anastomosis of the pyloric antrum with the jejunal conduit was manually completed by stratum anastomosis. Postoperatively, the procedure in group A alleviated gastrointestinal symptoms such as appetite loss, epigastric fullness, reflux esophagitis, early dumping syndrome, body weight loss, endoscopic reflux esophagitis, and endoscopic gastritis in the remnant stomach, postprandial stasis of the substitute stomach, and postgastrectomy cholecystolithiasis better than in group B. The results suggest that the proposed technique is a function-preserving gastric operation appropriate for preventing postgastrectomy disorder.