Reviews

Total gastrectomy: options for the restoration of

gastrointestinal continuity
Anthony C Chin and N Joseph Espat

Total gastric resection and the subsequent selection of the

optimum procedure for reconstruction of the oesophageal-
intestinal tract is a highly debated topic. Many different types
of reconstruction have been proposed, but attempts to
objectively validate the potential advantages of these
techniques of have not produced any definitive conclusions.
The main aim of reconstruction should be to maintain the
nutritional status and quality of life of the patient, with the
additional goal of achieving similar function to normal gut. In
this review, we discuss the prospectively randomised
studies of gastrointestinal reconstruction that were done
between 1987 and 2002.

Lancet Oncol 2003; 4: 271–76

During the latter half of the 20th century, there was a decline
in the incidence of the endemic (intestinal) form of gastric
carcinoma in the USA.1 By contrast, tumours arising from
the gastro-oesophageal junction and distal oesophagus—
which are associated with a type of oesophageal metaplasia
known as Barrett’s epithelium—have increased in
incidence.2 Despite its decline, however, the endemic form of
gastric cancer is one of the most common causes of death
from malignant disease.3 There are an estimated 798 000
annual cases worldwide, 21 900 of which occur in the USA.
Total gastric resection and the selection of the
appropriate operation for the reconstruction of the passage
between the oesophagus and the intestine is controversial
(figure 1). Many different types of reconstruction after total
gastrectomy have been proposed, but a great deal of research
is still being done to validate the potential advantages of
various procedures. The main focus of such reconstruction
should be to retain the nutritional status and quality of life of
the patient, and also to achieve similar function to that of a
normal gut. In this review, we discuss the prospective
randomised studies of gastrointestinal reconstruction after
total gastrectomy.
Considerations for reconstruction
The reconstruction of the intestinal tract after complete
gastric resection requires the restoration of the enteric flow
between the oesophagus and small intestine. More than 60
techniques have been described since Schlatter reported the
first successful total gastrectomy with reconstruction in
1897.4,5 These different methods of reconstruction
incorporate two basic concepts.
First, there is importance placed on the preservation of
the duodenal passage. It has been hypothesised that passage
of food across the duodenum, resulting in the mixture of
chyme with biliary and pancreatic secretions, aids in
digestion, absorption, and the stimulation of the remaining
Figure 1. Perioperative photograph taken during a total gastrectomy
operation.
intestinal tract.6,7 These processes should result in better
calcium and iron absorption with improved lipid and
protein digestion.8 In addition to preservation of the
duodenal passage, there should be no loop of jejunum
extending out of the oesophageal-intestinal passage. This
method, in theory, should maximise and stimulate the
remaining intestinal tract for caloric absorption in these
commonly malnourished patients.
Second, the formation of an appropriate replacement
gastric reservoir, to simulate pre-operative gastric volume, is
considered important. Construction of an enteric pouch—
eg, the Roux-en-Y, double jejunum, and aboral—is thought
to enable the patient to consume larger, more customary,
and satisfying meals.4,6 A pouch should therefore improve
the patients’ quality of life, allow them to ingest more
calories, and help to prevent malabsorption and weight loss.
Reconstructive procedures after total gastrectomy take
these considerations into account, and can be classed as:
● Duodenal passage and no pouch—reconstruction with
preservation of the duodenal passage but no pouch
formation—eg, jejunal interposition.9
● Duodenal passage with pouch—reconstruction with
both preservation of the duodenal passage and enteric
pouch—eg, jejunal interposition pouch, ␳-double tract,
jejunal double tract, and the Ulm pouch (figure 2).6,7,9–12
ACC and NJE are at the Department of Surgery, The University of
Illinois at Chicago, USA.
Correspondence: Dr N Joseph Espat, Department of Surgery,
University of Illinois at Chicago, 840 South Wood Street (M/C 958),
Chicago, IL 60012, USA. Tel: +1 312 355 1493.
Fax: +1 312 355 1987. Email: Jespat@uic.edu

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 Review Reconstruction after total gastrectomy

Nakane and colleagues9 published the

results from a similar trial. They
randomly assigned 30 patients (10 in
each group) to undergo Roux-en-Y with
or without pouch or jejunal interposition
with pouch. Patients were assessed for
amount of food intake in a single meal,
body weight, serum nutritional
parameters—eg, total protein, albumin,
and total cholesterol—and emptying
time 1 h after a semisolid meal labelled
with Technicium-99m. Follow-up data
up to 24 months after surgery showed
Ulm pouch Jejunal J-pouch ␳-double-tract that in patients who had a pouch, the
interposition double-tract preservation of duodenal passage
pouch significantly decreased the amount of
food intake within a single meal, and
Figure 2. Duodenal passage with pouch, eg, jejunal interposition pouch, ␳-double tract, jejunal patients took longer to return to pre-
double tract, or the Ulm pouch. illness normal body weight than patients
who had the Roux-en-Y reconstruction.
● No duodenal passage and no pouch—reconstruction There was no difference between the two groups in
with no preservation of the duodenal passage or nutritional factors. The reservoir function, as monitored by
construction of pouch—eg, the Roux-en-Y, loop radioisotope studies, showed that in the patients who had a
oesophageal jejunostomy (figure 3).6,8,11,13–18 pouch, nutrition was retained in the initial minutes after
● No duodenal passage with pouch—reconstruction ingestion. However, in the patients who had a jejunal
without preservation of the duodenal passage but interposition, the transmission from the pouch to the small
includes construction of pouch—eg, Roux-en-Y with intestines was delayed leading to sensation of epigastric
pouch, aboral pouch, or S pouch (figure 4).6,8,10,11,15,19 fullness or nausea. Video x-ray showed that the potential
cause of the delay could be the procedure itself; researchers
Duodenal passage preservation reported twisting in the jejunal conduit between the pouch
There are currently no prospective studies comparing and the duodenum in most patients. This problem
duodenal passage preservation with non-duodenal highlights the technical challenge of reconstruction with
preserving procedures after total gastrectomy. The limited preservation of duodenal passage.
number of prospective randomised studies (table 1) Nakane and colleagues12 have since revised their original
have compared the potential benefits of preserving jejunal interposition with pouch reconstruction by
duodenal passage with those of non-duodenal passage shortening the distance of their conduit from 20 cm to 10
reconstructions with formation of a pouch.6,10–12 In cm and widening the mesenteric pedicle to preserve the
the absence of studies exclusively investigating blood and nerve supply. They randomly assigned 30 patients
duodenal passage, we have considered duodenal-preserving to undergo the improved jejunal interposition procedure
procedures with a pouch.
Fuchs and colleagues10 randomly assigned 120 patients
to duodenal-preserving reconstructions of jejunal
interposition with pouch (n=53) or Roux-en-Y with pouch
(n=53). 14 patients were withdrawn and needed
reconstruction with a Roux-en-Y procedure because the
presence of a short mesentery or high intrathoracic
oesophageal stump meant that a jejunal interposition could
not be completed.
The study authors recorded operation time,
complications during and after the operation, body weight,
and functional assessment and quality of life with Visick
scoring and Spitzer’s index. There was no difference in the
complication rate postoperatively and 16 patients who had
Roux-en-Y with pouch and 20 patients who had jejunal
interposition with pouch showed no recurrence at 3-year Loop Simple
follow-up. Overall there was no significant difference oesophageal Roux-en-Y
between the two techniques. The authors concluded that jejunostomy
patients requiring total gastrectomy for gastric cancer do Figure 3. No duodenal passage and no pouch—eg, Roux-en-Y and loop
not benefit from a jejunal interposition reconstruction. oesophageal jejunostomy.

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 Reconstruction after total gastrectomy
Review

duodenal passage may be necessary to

aid the absorption of serum iron. They
also found that the peak and speed
of increases in serum glucose
concentration were significantly higher
in patients with Roux reconstruction.
However, the peak and speed of
increases in insulin concentration were
higher in patients who had the Ulm
procedure. Furthermore, the volume of
the pouch had no significant effect on
outcome. The authors conclude that
the complicated Ulm procedure should
only be used in patients for whom
the surgery-related morbidity and
Roux-en-Y Aboral pouch Double jejunum mortality are no greater than that for
with pouch pouch
simple reconstruction and who would
Figure 4. No duodenal passage with pouch—eg, Roux-en-Y with pouch, aboral pouch or S pouch. benefit from the surgery with regards to
food intake and qualify of life.
(n=15) or Roux-en-Y with pouch (n=15). Postoperative
symptoms of food intake in a single meal, body weight, Evidence for reconstruction with a pouch
serum nutritional factors—eg, total protein, albumin and Since Hunt first advocated construction of a food reservoir
total cholesterol—emptying time of the gastric substitute, in 1952,20 there have been several randomised studies
and gallstone formation were assessed. After a 2-year follow- (table 2) investigating the potential benefits of non-
up, the authors reported no clear advantage for the duodenal-passage reconstruction with and without pouch
preservation of duodenal passage in terms of function. They formation.6–9,11,13,14,16–18 Another study has assessed the
also reported no significant difference in dietary intake in a potential benefit of a pouch reconstruction in the presence
single meal, development of body weight, nutritional of a duodenal passage9 and two other studies have assessed
variables, and formation of gallstones. The only significant several different pouch reconstructions—either with7 or
difference was a higher initial retention rate in patients who without19 a duodenal passage.
had a Roux-en-Y procedure. On the basis of these findings, Troidl and colleagues13 were the first to assess the potential
the authors could not clarify the difference in outcome benefits of a pouch after total gastrectomy in a randomised
between the two procedures. trial. 38 patients were assigned to undergo Roux-en-Y with
Schwarz6 and co-workers investigated the benefit of an pouch (n=20) or oesophago-jejunostomy (n=18). They
Ulm pouch—a duodenal passage preserving jejunal assessed food resorption, caloric intake, body weight, survival,
interposition with pouch—compared with several and general well being. They reported some tentative
reconstruction methods. 60 patients were randomly assigned conclusions, but caution the interpretation of the results
to have an Ulm pouch 10 cm or 20 cm in length, a Roux-en- because of the small sample size. During the 3 months after
Y with pouch 10 cm or 20 cm in length, and a Roux-en-Y surgery, all patients reported a substantial decrease in their
without pouch. quality of life. The survival probability and disease-specific
6 months after total gastrectomy, the patients’ quality variables such as appetite, hunger, and food intake seem to
of life was assessed with a standardised questionnaire favour the Roux-en-Y reconstruction and the authors believe
and physical factors such as physiological regulation of that these patients had better long-term outcome.
gastrointestinal hormone (measured by
serum glucose, insulin, cholecystokin, Table 1. Studies evaluating preservation of duodenal passage
motilin, secretin, and pancreatic
polypeptide), and haemoglobin and Type of comparison Type of construction (n) Conclusion Ref
serum iron concentrations were NDPNP vs NDWP Roux-en-Y vs Roux-en-Y with 10 cm Better quality of life with 6
recorded. The authors reported a vs DPWP and 20 cm pouch vs 10 cm and 20 cm Ulm pouch, no advantage with
Ulm pouch increased pouch volumes
significant increase in quality of life NDPWP vs DPWP Roux-en-Y with pouch (53) vs jejunal No benefit from jejunal 10
with preservation of duodenal passage. interposition with pouch (53) interposition with pouch
They also reported an increase in NDPNP vs NDPWP Roux-en-Y (10) vs Roux-en-Y with
weight, although it was not significant, vs DPWP pouch (10) vs jejunal interposition with Roux-en-Y with pouch better 11
whereas patients with Roux pouch (10)
reconstruction continued to lose NDPWP vs DPWP Roux-en-Y with pouch (15) vs jejunal No clear advantage of jejunal 12
weight. The concentrations of iron and interposition with pouch (15) interposition with pouch
Ulm pouch increased pouch volumes
haemoglobin were significantly higher
in patients in the Ulm reconstruction NDPWP, no duodenal passage with pouch: DPWP, duodenal passage with pouch; NDPNP, no duodenal passage and

group, which suggests that the no pouch.

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 Review Reconstruction after total gastrectomy

Table 2. Studies evaluating pouch reconstruction

circumference, concentrations of
serum albumin and total serum
Type of comparison Type of construction (n) Conclusion Ref protein, nutritional habits, such as
NDPNP vs NDPWP Roux-en-Y vs Roux-en-Y with 10 cm or Better quality of life with 6 number of meals, energy intake, and
vs DPWP 20 cm pouch vs 10 cm or 20 cm Ulm pouch, no advantage
Ulm pouch (10 in each) with increased pouch
disturbances after meals, and
volumes emptying time. In 27 patients, there
DPWP vs DPWP Jejunal-pouch double-tract (20) Mixed results with no 7 were no differences in morbidity or
vs r-double-tract (20) recommendation mortality, emptying time, frequency
NDPNP vs NDPWP Roux-en-Y (22) vs aboral pouch (24) Better quality of life with 8 of meals, or changes in body weight
aboral pouch at 2-year follow-up. Symptoms
DPNP vs DPWP Jejunal interposition (18) vs jejunal No benefit from pouch 9 occurring after eating were more
interposition with pouch (21) frequent in patients who did not have
NDPNP vs NDPWP Roux-en-Y (10) vs Roux-en-Y with Roux-en-Y with pouch 11 a pouch; however, these were not
vs DPWP pouch (10) vs jejunal interposition with better, duodenal passage enough to warrant increasing caloric
pouch (10) poor
intake to maintain weight. There was
NDPNP vs NDPWP Loop oesophago-jejunostomy (18) vs Sample size too small for 13 no association between the surgical
Roux-en-Y with pouch (28) significant conclusion.
Patients surviving at least
procedure and energy intake, although
1 year after Roux-en-Y with energy intake was statistically related
pouch tend to do better to body mass index. The authors
NDPNP vs NDPWP Roux-en-Y (24) vs Roux-en-Y with No benefit from pouch 14 therefore concluded that nutritional
pouch (24) intake was a greater determinant of
NDPNP vs NDPWP RY (49) vs SP (28) vs subtotal Clinical advantage with 16 nutritional status than a gastric
vs subtotal gastrectomy gastrectomy (12) pouch reservoir, and that use of a pouch in
NDPNP vs NDPWP Roux-en-Y (23) vs Roux-en-Y with At 15 months, patients with 17 the Roux-en-Y reconstruction was of
pouch (26) pouch had better eating
no added benefit.
capacity and fewer
postoperative symptoms Liedeman and co-workers15
NDPNP vs NDPWP Roux-en-Y (14) vs Roux-en-Y with Pouch construction is 18
studied the role of an S-shaped gastric
pouch (21) recommended substitute after gastrectomy. They
NDPWP vs NDPWP Roux-en-Y with pouch (18) vs jejunal Better nutritional parameters 19 randomly assigned 28 patients to
double pouch (23) and quality of life with jejunal S-shaped pouch reconstruction,
double pouch 49 patients to Roux-en-Y recon-
NDPNP, no duodenal passage and no pouch; NDPWP, no duodenal passage with pouch; DPWP, duodenal passage struction, and 12 to subtotal
with pouch; DPNP, duodenal passage and no pouch. gastrectomy, based on location of the
tumour. The authors initially
The aforementioned studies by Nakane and colleagues11 concluded that construction of a gastric reservoir did not
and Schwarz and colleagues6 on duodenal preservation improve nutritional adaptation after surgery. However, they
included patients who had Roux-en-Y reconstruction have since evaluated long-term data of gastric substitute
without a pouch. Nakane and colleagues reported that these (n=13) and simple Roux-en-Y (n=23) procedures in
patients had a higher incidence of bile reflux, lower dietary patients who were alive more than 3 years after resection
intake after a single meal, and lower total protein (none of the subtotal gastrectomy group had survived) and
concentrations than those who had a Roux-en-Y with a found that patients with a gastric substitute had significantly
pouch. In fact patients who were given a pouch had a higher higher percentage changes in body fat than patients who had
prognostic nutritional index at 12 and 24 months. The the Roux-en-Y procedure.16 As well as weight gain, patients
researchers also reported very rapid emptying times and no with a gastric reservoir showed increases in tricep skin-fold
reservoir function in patients who had a reconstruction thickness, whereas patients who had a simple Roux-en-Y
without pouch, whereas the patients who had a pouch reconstruction showed decreases. In the initial study, in
showed retention of food with graduated emptying. Schwarz which patients who had a gastric reservoir complained more
and colleagues found no differences in body weight or frequently of difficulties consuming adequate amounts of
concentrations of various gastrointestinal hormones in food, the authors concluded that a period of adaptation was
patients who had a Roux-en-Y with a pouch reconstruction necessary. On the basis of the slight trend towards increased
than those who did not have a pouch. However, patients food intake and a tendency towards reduced loss of fecal
with a pouch had a higher quality of life score. Both these nutrition in patients with a gastric reservoir, the authors now
studies support formation of a pouch and Schwarz and conclude that gastric substitute reconstruction carries a
colleagues recommend the reconstruction in the form of an long-term clinical advantage of weight gain.
Ulm pouch but add that the volume of the pouch does not Iivonen and colleagues did several studies over a 4-year
make a difference to the outcome. period comparing jejunal pouch with Roux-en-Y
Bozzetti and colleagues14 randomly assigned 48 patients reconstruction.17 They randomly assigned 49 patients to
to undergo Roux-en-Y reconstruction with (n=24) or undergo one of the two procedures. At 15-month follow-up
without (n=24) a pouch. They measured body weight, arm they found that emptying (assessed by solid isotope) was

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 Reconstruction after total gastrectomy
Review

significantly slower in patients who had pouch

reconstruction. Dumping was more common in the Roux-
en-Y group and patients with a pouch were able to eat a
more normal sized meal. Weight gain, haemoglobin, and
albumin concentrations were the same in both groups.
The authors have since published long-term data after a
randomised study of 51 patients; they evaluated 20 patients
who had reconstruction with pouch and 14 patients with
Roux-en-Y reconstruction all of whom had survived at least
3 years.18 Indicators of postoperative food intake, such as
number of meals and eating capacity, were assessed with a
standard questionnaire. Weight loss, nutritional factors, and
upper-intestinal endoscopy examinations were also included
in the results. The authors reported that patients who had a
Roux-en-Y procedure had a significantly higher degree of
dumping, and were more likely to experience early satiety
and lower eating capacity, resulting in more meals per day
and greater weight loss. None of the patients developed
oesophagitis or pouchitis. The authors recommended that
reconstruction after total gastrectomy should be in the form
of a jejunal pouch.
Horvath and colleagues developed the technique of an
aboral pouch in 1997 and did a randomised study of
46 patients comparing the new procedure (n=24) with
Roux-en-Y without pouch (n=22).8 Anthropometric Figure 5. An upper intestinal contrast study showing oesophageal-
measurements, and factors indicative of nutritional status, intestinal reconstruction after total gastrectomy. The feeding jejunostomy
tube is visible on the right.
absorption, transit, and quality of life were assessed during
the study. The authors reported no significant difference in
body weight or body mass index and there was also no but most patients were assessed 12 months after surgery.
difference in total protein, albumin, triglyceride Total protein and albumin concentrations were significantly
concentration, white blood cells, haemoglobin, iron, total higher in patients in the jejunal-pouch double-tract group,
iron binding capacity, immunoglobin, and transferrin but there was no difference between the two groups in serum
measurements in serum samples. However, the total cholesterol concentrations, percentage body weight, or food
cholesterol concentration was significantly higher in patients intake. The scintigraphic evaluation of intestinal-
with the aboral pouch. Small studies of bowel scintigraphy oesophageal reflux was significantly higher in patients who
seemed to show a slower transit time with the aboral pouch, had ␳-double-tract reconstruction, but no significant
but this was not significant. There was no difference in difference was seen in the reflux score, emptying time, or
carbohydrate absorption, but at 6 months there was better dumping score. Furthermore, there was no significant
lipid absorption in patients with the aboral pouch, which difference on endoscopic follow-up between the two groups.
was not reported at 1-year follow-up. The gastrointestinal On the basis of these mixed results, the authors could not
quality-of-life index showed better results for patients who make any conclusions regarding any benefits of one pouch
had undergone pouch reconstruction. The authors over the other.
concluded that the aboral pouch is a feasible reconstruction Gioffre-Florio and co-workers did a study of 45
after total gastrectomy. patients who either received a reconstruction with a simple
Schmitz and co-workers studied the potential benefits of Roux-en-Y with pouch (n=18) or reconstruction with a
a pouch with the preservation of duodenal passage.9 They second infra-mesocolic pouch, known as the double jejunal
randomly assigned 29 patients to jejunal interposition pouch (n=23).19 At 12-month follow-up, 14 patients who
(n=18) or jejunal interposition with pouch (n=21) and had a simple pouch and 18 patients who had a double
evaluated quality of life with Spitzer’s index and Cuschieri’s pouch were available for comparative studies. A
assessment. There was no difference in either index for significantly higher number of patients who had the
postoperative quality of life. However, it is unclear if the double-pouch procedure had good Cuschieri grading and
maintenance of duodenal passage may have masked the lower Visick grading than those who had a single pouch,
potential benefits of pouch reconstruction that has been suggesting a possible increase in quality of life with the
observed in other studies. double procedure. The patients in the double pouch group
Two randomised studies have compared two different also showed significant trends toward normal weight range,
types of pouch reconstruction. Fujiwara and colleagues albumin, and total protein, with no difference in
randomly assigned 40 patients to jejunal-pouch double-tract haemoglobin. This study indicated that a second pouch is
reconstruction (n=20) or ␳-double-tract reconstruction associated with an increase in specific nutritional value and
(n=20).7 The patients were followed up over 6–24 months, an increase in quality of life.

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 Review
Search strategy and selection criteria
Data for this review were identified by searches of Medline,
Current Contents, PubMed, and references from relevant
articles with the search terms “total gastrectomy”,
“reconstruction and total gastrectomy”, “total gastrectomy
and reconstruction” and “randomised clinical trial”. Only
papers published in English between 1987 and 2002 were
included.
Conclusion
On the basis of the data from prospective clinical studies we
use the technique of jejunal pouch with a Roux-en-Y
oesophago-jejunostomy reconstruction (or Hunt-Lawrence-
Rodino pouch) after total gastrectomy. Furthermore, we
prefer to place a feeding jejunostomy tube at the time of the
procedure to optimise postoperative nutrition (figure 5).
Our choice of reconstruction is based on several
potential benefits, such as the need for one less entero-
entero anastamosis than with a duodenal passage
preserving procedure,10 the potential prevention of alkaline
reflux oesophagitis,9 and the avoidance of potential
technical limitations associated with the formation of a
duodenal passage.10,11 However, we recognise that our
choice of procedure is not the conclusion of an objective
clinical study but an assessment based on previous studies,
which have highlighted the potential advantage of this
approach.
Each of the randomised prospective studies we have
included in this review used different endpoints and
conceptually similar, but varied, operations. Furthermore,
there are conflicting conclusions regarding the benefit of
duodenal passage preservation and the usefulness of an
enteric reservoir. Overall the studies suggest a benefit for
reconstruction with pouch, and show little evidence to
warrant the additional technical demands of the
reconstruction of the duodenal passage. Further randomised
and standardised studies are necessary to fully elucidate the
optimum approach in restoring intestinal continuity after
total gastrectomy.
Until the optimum method for reconstruction can be
determined, investigators need to continue to systemically
define the appropriate quality of life indices and objective
parameters for comparisons of the various techniques
available for reconstruction after total gastrectomy.
Conflict of interest
None declared.
Acknowledgments
We would like to thank Lloyd M Nyhus for his help and guidance in the
preparation of this manuscript and David Jho for his assistance with the
figures.
276
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Reconstruction after total gastrectomy
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