Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.

间置空肠代胃吻合术与Roux-en-Y代胃手术对患者术后生存质量的影响分析

目的研究分析间置空肠代胃吻合术和Roux-en-Y代胃手术对患者术后生存率的影响。方法抽取我院2010年10月~2016年10月间收治的胃癌患者110例作为研究对象,所有患者均行根治性胃切除手术治疗,将其按照术后消化道重建的方式不同分为两组,每组各有55例,A组患者采用间置空肠代胃吻合术,B组患者采用Roux-en-Y代胃手术,分别对两组患者的手术时间,消化道重建时间,术中出血量,近远期并发症发生率,消化道重建后的营养状况,对化疗毒性的耐受性、消化道重建后生活质量等指标进行比较。结果 A组患者的消化道重建时间短于B组,切口感染、淋巴漏、早饱症、倾倒综合征、反流性食道炎发生率显著低于B组,对化疗毒性的耐受性显著优于B组,术后12个月的Hb、PA、TP检测水平以及消化道重建后的生活质量总评分均显著高于B组,比较有统计学差异(P<0.05)。结论实施根治性全胃切除手术治疗后的胃癌患者,间置空肠重建比Roux-en-Y重建方式具有更优的生活质量、更好的营养状况、反流性食管发生率更低、更好的化疗耐受性、胃排空功能更强及更轻微的内分泌改变,颇具临床推广应用价值。