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In Search of the Optimal Reconstruction Method after Total Gastrectomy. Is Roux-en-Y the Best? A Review of the Randomized Clinical Trials.
Naum, C, Bîrlă, R, Marica, DC, Constantinoiu, S
Chirurgia (Bucharest, Romania : 1990). 2020;(1):12-22
Abstract
Background: Numerous procedures for reconstruction after total gastrectomy have been proposed in order to achieve the lowest postoperative morbidity. Roux-en-Y esojejunostomy is widely accepted as a standard reconstruction technique due to its simplicity and its satisfactory nutritional outcomes. The construction of a gastric pouch and the maintenance of the duodenal transit have been proposed to ameliorate the quality of life of patients with gastric cancer. The aim of this study is to assess the quality of life of patients with different types of reconstruction after total gastrectomy. Material and Method: A systematic literature search was performed in PubMed, Science Direct, Wiley Online, Springer Link, up to December 1, 2019. Only original articles published in English were included. Quality of life was measured using different instruments. Postoperative aspects of reflux oesophagitis, dumping syndrome, food intake and weight status were evaluated. Results: 15 studies were included in this research. Three techniques for restoring the digestive tract continuity were compared: Roux-en-Y eso-jejunostomy, jejunal interposition and gastric pouch construction. The statistical results of the included studies were evaluated in terms of quality of life or weight status. Conclusions: The length of the alimentary limb for prophylaxis of eso-jejunal reflux should be at least 50 cm, but not more than 60 cm for the prevention of malabsorption. The quality of life was significantly better in patients with gastric pouch. Maintaining the duodenal transit does not seem to bring any benefit in quality of life or weight status, even if this is a physiological way.
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2.
Outcomes for jejunal interposition reconstruction compared with Roux-en-Y anastomosis: A meta-analysis.
Fan, KX, Xu, ZF, Wang, MR, Li, DT, Yang, XS, Guo, J
World journal of gastroenterology. 2015;(10):3093-9
Abstract
AIM: To compare the clinical outcomes between jejunal interposition reconstruction and Roux-en-Y anastomosis after total gastrostomy in patients with gastric cancer. METHODS A systematic literature search was conducted by two independent researchers on PubMed, EMBASE, the Cochrane Library, Google Scholar, and other English literature databases, as well as the Chinese Academic Journal, Chinese Biomedical Literature Database, and other Chinese literature databases using "Gastrostomy", "Roux-en-Y", and "Interposition" as keywords. Data extraction and verification were performed on the literature included in this study. RevMan 5.2 software was used for data processing. A fixed-effects model was applied in the absence of heterogeneity between studies. A random effects model was applied in the presence of heterogeneity between studies. RESULTS Ten studies with a total of 762 gastric cancer patients who underwent total gastrostomy were included in this study. Among them, 357 received jejunal interposition reconstruction after total gastrostomy, and 405 received Roux-en-Y anastomosis. Compared with Roux-en-Y anastomosis, jejunal interposition reconstruction significantly decreased the incidence of dumping syndrome (OR = 0.18, 95%CI: 0.10-0.31; P < 0.001), increased the prognostic nutritional index [weighted mean difference (WMD) = 6.02, 95%CI: 1.82-10.22; P < 0.001], and improved the degree of postoperative weight loss [WMD = 2.47, 95%CI: -3.19-(-1.75); P < 0.001]. However, there is no statistically significant difference in operative time, hospital stay, or incidence of reflux esophagitis. CONCLUSION Compared with Roux-en-Y anastomosis, patients who underwent jejunal interposition reconstruction after total gastrostomy had a lower risk of postoperative long-term complications and improved life quality.
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3.
No gut syndrome: near total enterectomy.
Huerta, S, Kukreja, S, Carter, K, Butler, D
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2015;(5):973-80
Abstract
In adult patients, removal of the entire jejunum and ileum (a near total enterectomy (NTE)) is considered a non-survivable event as patients undergoing this procedure might also suffer from an underlying illness that will lead to bowel necrosis such as septic or cardiac shock and respiratory failure. Parenteral nutrition (PN) dependency with its associated complications and quality of life issues further complicates management decisions in this group of patients. In the following report, we discuss our institutional experience with NTE and present a comprehensive review of the literature with patients undergoing NTE with the establishment of bowel continuity and successful outcomes even in cases dating as far back as the 1950s, over a decade prior to the implementation of PN. Review of the literature revealed 26 cases of NTE. Most of these patients are young (46.7 years old), and 57 % are women. These patients were reported to be alive at 21 months of follow-up. In this report, we present an individual 51 months following NTE. We also document the oldest patient receiving an NTE (76 years old). Both of these patients are alive on home PN. In cases where there is hemodynamic stability and patients request to continue with further care, the possibility of a NTE with bowel continuity and life-long PN might be entertained.
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Unwanted effects and interaction of intrajejunal levodopa/carbidopa administration.
Jost, WH
Expert opinion on drug safety. 2014;(4):447-58
Abstract
INTRODUCTION Levodopa is the most effective treatment for Parkinson's disease. After a number of years on treatment, fluctuations and dyskinesias may develop. Hence, invasive treatment measures are often needed (escalation therapy). AREAS COVERED Twenty years ago, a levodopa/carbidopa intestinal gel (LCIG) that can be infused directly into the jejunum was developed. This provides for continuous dopaminergic stimulation. For the past 10 years, LCIG has been licensed in some countries and its marketing approval is pending in the USA. It is endowed with very good efficacy, and in studies, it has proven to be superior to oral drug treatment. Continuous dopaminergic stimulation is also assured, and fluctuations and dyskinesias are significantly reduced. However, this technique involves an invasive procedure with percutaneous endoscopic gastrostomy and attendant surgical and postsurgical complications. Besides, there are problems related to the pump and tube. Vitamin deficiency and polyneuropathies are other drawbacks. EXPERT OPINION LCIG is a beneficial and very useful treatment option as escalation therapy for Parkinson's disease. While the side effects are not insignificant, they are justifiable in view of the severity of the disease. Attention must be paid, in particular, to malabsorption, with monitoring at baseline and in the course of treatment.
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5.
Composition and physicochemical properties of fasted-state human duodenal and jejunal fluid: a critical evaluation of the available data.
Fuchs, A, Dressman, JB
Journal of pharmaceutical sciences. 2014;(11):3398-3411
Abstract
Various methods of sampling and analyzing intestinal fluids have been applied over the years. In this report, data that have been published to date about the composition of fasted-state human intestinal fluid (HIF) and its physicochemical properties are summarized and the influence of the methods used to generate the data is discussed. Key physiological parameters summarized include pH, buffer capacity, osmolarity, and ionic strength in both the fasted duodenum and jejunum. Furthermore, the bile salts and phospholipids in the fasted small intestine are addressed in terms of both qualitative and quantitative composition with respect to the different types and degrees of hydroxylation of bile salts. Taurocholate, glycocholate, and glycochenodeoxycholate were identified as the main bile salts. Lysolecithin was identified as the predominant phospholipid species in fasted HIF because of the enzymatic degradation of lecithin. Together with other intestinal surfactants, such as cholesterol and free fatty acids, the influence of bile acids and phospholipids on the surface tension of fasted HIF was evaluated. A good working knowledge of all the above-mentioned parameters is important to optimize the composition of biorelevant media, with a view to improving the prediction of in vivo dissolution and release performance of drugs and dosage forms.
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6.
Meta-analysis of two types of digestive tract reconstruction modes after total gastrectomy.
Wang, G, Ceng, G, Zhou, B, Chen, Y, Jin, C, Feng, X
Hepato-gastroenterology. 2013;(127):1817-21
Abstract
BACKGROUND/AIMS: This study aims to evaluate the application value of two reconstruction technique types, namely, Roux-en-Y reconstruction with pouch (RYP) and jejunal interposition with pouch (JIP), after total gastrectomy. METHODOLOGY MEDLINE, EM-BASE, PubMed, CBM, and Vol. 2, 2010 of the Cochrane Library were indexed using computers, whereas relevant Chinese journals were manually indexed. After including total gastrectomy, random RYP and JIP control tests and evaluations on their methodological quality were conducted. Revman 5.1 software was utilised for the statistical analysis. RESULTS Three random control tests that included patients of 166 cases were performed. Meta-analysis results indicated that RYP involved a shorter operation time than JIP (WMD = -17.27, 95% CI = -29.58 to -4.96). For postoperative complications (OR = 0.73, 95% CI = 0.33 to 1.59), no substantial differences were found in bile reflux (OR = 0.19, 95% CI = 0.04 to 0.94), postoperative nutritional status, and weight. CONCLUSIONS The application value of RYP and JIP clinical results need further random control research to fully evaluate their efficacies.
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Diagnosis and management of small intestinal bacterial overgrowth.
Bohm, M, Siwiec, RM, Wo, JM
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2013;(3):289-99
Abstract
Small intestinal bacterial overgrowth (SIBO) can result from failure of the gastric acid barrier, failure of small intestinal motility, anatomic alterations, or impairment of systemic and local immunity. The current accepted criteria for the diagnosis of SIBO is the presence of coliform bacteria isolated from the proximal jejunum with >10(5) colony-forming units/mL. A major concern with luminal aspiration is that it is only one random sampling of the small intestine and may not always be representative of the underlying microbiota. A new approach to examine the underlying microbiota uses rapid molecular sequencing, but its clinical utilization is still under active investigation. Clinical manifestations of SIBO are variable and include bloating, flatulence, abdominal distention, abdominal pain, and diarrhea. Severe cases may present with nutrition deficiencies due to malabsorption of micro- and macronutrients. The current management strategies for SIBO center on identifying and correcting underlying causes, addressing nutrition deficiencies, and judicious utilization of antibiotics to treat symptomatic SIBO.
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8.
The duodenal-jejunal bypass sleeve (EndoBarrier Gastrointestinal Liner) for weight loss and treatment of type 2 diabetes.
Patel, SR, Hakim, D, Mason, J, Hakim, N
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2013;(3):482-4
Abstract
BACKGROUND Surgical intervention is now the most effective modality with which to treat severe obesity. There is currently a lack of minimally invasive technology with which we can effectively treat obesity and reverse type 2 diabetes mellitus. The EndoBarrier is a fluoropolymer sleeve that is reversibly fixated to the duodenal bulb and extends 80 cm into the small bowel, usually terminating in the proximal jejunum. This endoscopically inserted device aids weight loss through malabsorption and activating hormonal triggers. METHODS We conducted a nonsystematic review on worldwide articles published on the MEDLINE database to ascertain progress in the development and use of the EndoBarrier. RESULTS Most studies used 12-week excess weight loss (EWL) as a primary outcome measure with results ranging from 11.9%-23.6%. One study to date used 52-week EWL as its primary measure with a significant outcome of 47%. Our group has seen this technology cause significant weight loss, resolution of type 2 diabetes mellitus, and improvement in cardiovascular risk factor profile. CONCLUSIONS The EndoBarrier shows promise in the surgical weight loss arena. This review article summarizes the technical aspects of this new technology, provides preliminary efficacy results, and introduces the roles it may play in the future of bariatric surgery.
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9.
Is a distal jejunojejunal pouch nutritionally ideal in total gastrectomy?
Nadrowski, L
American journal of surgery. 2003;(4):349-53
Abstract
The question arises whether it is important to construct a gastric replacement reservoir, after a total gastrectomy. Creating a noncomplicated and easily constructed capacious antiperistaltic distal jejunojejunal pouch at the Roux-en-Y site should further improve nutritional satisfaction and weight gain, particularly in patients with gastric cancer.