1. Prof. G. de Manzoni “Recenti acquisizioni fisiopatologiche post chirurgia digestiva maggiore” STOMACO Bari, November 8th University of Verona Department of Surgery Division of Upper G.I. Surgery Prof. G. de Manzoni

2. Gastric Physiology LES His Angle Pacemaker region Pyloric sphincter Allow: o bolous transit o Mix of the bolous Avoid: o acid reflux o biliary reflux o quick passage in the duodenum

3. Gastric Physiology Parietal cells Mucus cells HCl production Protection

4. Gastric Physiology Vagus nerve Celiac plexus o Motility o Secretions

5. Gastric Pathology Peptic Ulcer Cancer Obesity Main V Cancer of gastric stump

6. Surgical goals Resection Reconstruction o Resection margins (T0) o Nodal dissection (N0) o Acid-Biliary reflux o Good emptying o Number of meals o Body weight o QOL

7. Surgical goals The importance of QOL… Cunningham D, et al. (2006) N Engl J Med CT group: 36% Surgery alone: 23% 5 y OS for advanced gastric cancer

8. “cutting less does not always lead to better results…” Surgical goals

9. Gastric resections Total Gastrectomy JGCA (2011) Gastric Cancer

10. Distal Gastrectomy JGCA (2011) Gastric Cancer o Distal gastric tumors o ≥ 3 or 5 cm proximal margin (according to growth pattern) Gastric resections

11. Pylorus Preserving JGCA (2011) Gastric Cancer o Middle gastric tumors o ≥ 4 cm from pylorus Gastric resections

12. Proximal Gastrectomy JGCA (2011) Gastric Cancer o Proximal tumors o ≥ ½ distal stomach preserved Gastric resections

13. Gastric reconstructions Total Gastrectomy Roux-en-Y Longmire interposition o Less biliary reflux o Preservation of physiological route o Improved absorption o Reduced weight loss

14. Gastric reconstructions Total Gastrectomy o Review of 9 RCT (1985-2009) o Roux-en-Y VS Longmire interposition Body weight No Differences QOL Esophagitis Mariette, et al.(2010) J Visc Surg

15. Gastric reconstructions Total Gastrectomy o Multicenter RCT (105 pz) o Roux-en-Y VS Longmire interposition QOL No Differences Ishigami, et al.(2011) Am J Surg

16. Gastric reconstructions Pouch or not? Principles: o Increase food intake at each meal o Prevent dumping syndrome o Prevent reflux esophagitis (?) Better QOL?

17. Gastric reconstructions Pouch or not? Dumping syndrome o 9 RCT Roux-en-Y (474 pz) Eating capability Body weight Long term better QOL… Gertler, et al.(2009) Am J Gastroenterol Pouch is better in…

18. Total Gastrectomy… In Japan Kumagai, et al.(2012) Surg Today o 145 Japanese institutions o 138 use Roux-en-Y reconstruction o 26 institutions performs Pouch 95% Roux-en-Y reconstruction Gastric reconstructions

19. Mariette, et al. (2010) J Visc Surg Distal Gastrectomy Roux-en-Y Billroth I Billroth II (+ Braun) o Restore physiologic path o Always possible without tension o Less biliary reflux Gastric reconstructions

20. Csendes, et al. (2009) Ann Surg Distal Gastrectomy Roux-en-Y Billroth II VS o 75 pz (mean fu 182-193 months) o Surgery for peptic ulcer Less reflux for Roux in long term follow-up Gastric reconstructions

21. Lee, et al. (2012) Surg Endosc Distal Gastrectomy Roux-en-Y Billroth II + Braun VS o 159 pz (12 months fu) o Prospective randomized trial Endoscopic findings Biliary reflux 3.7% Roux vs 75% BII Hepatobiliary scan Gastric reconstructions

22. Distal Gastrectomy Roux-en-Y Billroth I Billroth II (+ Braun) o High biliary reflux Gastric reconstructions

23. Inokuchi, et al. (2012) Gastric Cancer Nunobe, et al. (2007) Int J Clin Oncol Distal Gastrectomy Roux-en-Y Billroth I VS Gastritis Esophagitis Food residue Biliary reflux Endoscopic findings Better for Roux Gastric reconstructions

24. Inokuchi, et al. (2012) Gastric Cancer Sano, et al. (2007) Int J Clin Oncol Distal Gastrectomy Roux-en-Y Billroth I VS Endoscopic findings Gastric reconstructions o Esophagitis o Gastritis o Food residue o Bile reflux P<0.05 Better for Roux

25. Lee, et al. (2012) Surg Endosc Distal Gastrectomy Roux3.7% Biliary Reflux Roux-en-Y Billroth I VS o 159 pz (12 months fu) o Prospective randomized trial Hepatobiliary scan Billroth I 56.3% Gastric reconstructions

26. Takiguchi, et al. (2012) Gastric Cancer Distal Gastrectomy Roux-en-Y Billroth I VS o 268 pz (21 months median fu) o Multicenter randomized phase II EORTC QLQ-C30 NO differences in QOL Gastric reconstructions

27. Distal Gastrectomy Roux-en-Y Billroth I o High biliary reflux o High gastritit o High esophagitis o High food residue NO differences in QOL… but Gastric reconstructions

28. Roux-en-Y o Less biliary reflux o Less gastritis o Less esophagitis o Less food residue o Roux stasis syndrome o Difficult endoscopic management of bile ducts Gastric reconstructions

29. Distal Gastrectomy… In Japan Kumagai, et al.(2012) Surg Today o 145 Japanese institutions o 112 (77%) use B1 reconstruction as first choice o 30 (21%) use Roux reconstruction as first choice 77% B1 21% Roux Gastric reconstructions

30. Pylorus Preserving Billroth I Evolution o Less dumping syndrome o Less gastritis o Less reflux esophagitis o Less gallbladder stones o More delayed gastric emptying o (Limited oncological dissection) Pros Cons

31. Morita, et al.(2008) Br J Surg Preservation of hepatich and pyloric branchs Preservation of coeliach branch Preservation of infrapyloric vessels o 611 pz (50 months median fu) Gastric reconstructions

32. Pylorus Preserving o 39 pz (40 months mean fu) o Pylorus preserving VS Billroth I Park, et al.(2008) World J Surg But… Better Symptom score Delayed Gastric emptying for solids Scintigraphic system Gastric reconstructions

33. Proximal Gastrectomy ProsCons Reflux esophagitis Improved nutrition Anastomotic stricture Theoretically better for early stages proximal cancer and Siewert III because of better QOL… Gastric reconstructions

34. Proximal Gastrectomy Kim, et al.(2012) Gastric Cancer Laparoscopy assisted proximal gastrectomy VS total gastrectomy o 131 pz o Endoscopic evaluation for stenosis o Modified Visick score for GERD High Stenosis High GERD Gastric reconstructions

35. Proximal Gastrectomy Kim, et al.(2012) Gastric Cancer Same nutritional status No advantages for PG instead of TG… Gastric reconstructions

36. Our experience (2000-2010) 50 pz Siewert II 24 pz Siewert III 26 pz o Short gastric conduit reconstruction o T-T mediastinal anastomosis

37. Our experience (2000-2010) Endoscopic diagnosis

38. Cardias adenocarcinoma Ivor Lewis Siewert III Total gastrectomy Proximal gastrectomy Siewert II Siewert I Total gastrectomy Ivor Lewis

39. Ivor Lewis – Personal Tecnique o Narrow gastric conduit o Intramediastinical conduit position o GERD reduction

40. Termino-Terminal Anastomosis o Better vascularization o Avoids the “could de sac” o Without weaknesses

41. Prefer intrathoracic anastomosis o Eases the venous outflow o Less tension on the anastomosis o Over-azygos for GERD reduction o Shorter conduit with better vascularization

42. Our experience until 2010 o Ivor Lewis o EAC + SCC o PPI for 12 months post-op

43. Velanovich, et al.(2007) Dis Esophagus QOL questionnaire o Good reliability o Good responsiveness o Good praticality (2 minutes)

44. ...2011 results o Ivor Lewis o EAC + SCC o PPI for 12 months post-op

45. Prophylactic Cholecistectomy? Rationale o Higher risk of gallstones formation  Vagal denervation  Postoperative fasting  Extent of lymphadenectomy  Extent of gastric resection  Digestive reconstruction o Difficult endoscopic management (Roux-en-Y) o Higher morbi-mortality for subsequent cholecistectomy

46. hepatich branch of vagus nerve Alteration in hormons production: cholecystokinin and secretin Altered motility Altered secretions Physiophatology

47. Cholelythiasis In general population 10% Symptomatic in 30% 15-25% develop cholelythiasis …5 y after gastric surgery

48. Gillen, et al.(2010) World J Surg o 16 studies (retrospective and prospective) o 3735 pz CCE: cholecistectomy High morbidity in delayed CCE Low additional morbidity for the whole cohort

49. Gillen, et al.(2010) World J Surg o 16 studies (retrospective and prospective) o 3735 pz Simultaneous cholecystectomy seems not to be necessary

50. Bernini, et al.(2012) Gastric Cancer o RCT – end of recruitment analysis o Propylactic cholecystectomy (PC) VS standard surgery (SS) o Roux-en-Y and Billroth II Perioperative complications Biliary: PC 1.5% vs SS 0% N.S. Overall: PC 25% vs SS 17% N.S. 1 pz: Bile from drainage: Conservative management (desappear in a few days)

51. Giacopuzzi S, de Manzoni G…Cordiano C, et al.(2008) Biliary Lithiasis Prophylactic cholecystectomy Extended lymphadenectomy (D2-D3) Total Gastrectomy Early stage (long survivor) PC

52. Nothing is perfect… but everything can be improved… but everything can be improved…