E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)
Methods for reconstruction
Total gastrectomy (Fig. 12.1d) is performed in all cancer patients where a distal or proximal gastrectomy cannot be performed due to oncological radicalness concerning the distance of resection margins towards the tumor, i.e., in adenocarcinomas greater than T2 of the proximal stomach, hereditary (CDH1 mutated) diffuse gastric cancer or signet ring gastric cancer with an insufficient proximal margin. The following reconstructions are most frequently used:
- RY is characterized by an esophago-jejunostomy of the remaining esophagus to an ascended jejunal limb and a jejuno-jejunostomy between the ascended jejunum to the first jejunal loop. The reconstruction can be performed with and without a pouch.
- Jejunal or colonic interposition: in the first case characterized by an esophago-jejunostomy and a jejuno-duodenostomy of an interposed jejunal segment. The formation of a pouch can be included in the reconstruction. Similarly, a segment of the colon, i.e., the transverse colon or an ileo-cecal segment can be interposed.
The RY reconstruction after total gastrectomy is similar to the RY after distal gastrectomy and has been described first by Orr in 1947 . The technique is similar to the RY after distal gastrectomy and consists of the formation of an esophago-jejunostomy of the remaining esophagus to a jejunal limb, which has been brought up either via the retrocolic (transmesocolic) or antecolic route (Fig. 12.3a). The length of the jejunal segment that has been brought up and thus excluded from the original small intestinal passage is often longer than in the case of RY reconstruction after distal gastrectomy. The esophago-jejunostomy is commonly performed as an end-to-side anastomosis, resulting in a blind ending of the jejunum (jejunal stump), which should be as short as possible.
Jejunal and colonic interposition
In order to keep the duodenum in the continuity of the intestinal passage the interposition of a jejunal segment after a partial removal of the stomach has already been used by Roux in 1907 . Longmire was the first to apply this technique after total gastrectomy  (Fig. 12.3b). The interposition requires the identification of a long enough jejunal segment (25–30 cm) close to the ligament of Treitz fed by a sufficient jejunal artery. Two anastomoses (a proximal esophagojejunostomy and a distal jejunoduodenostomy) re-establish the continuity of the intestinal continuity. Different parts of the colon have also been used to replace the missing stomach [26, 27]. The interposition of a colonic segment is technically more demanding and has not been shown to bring advantages over the jejunal interposition in a randomized trial.
Reconstruction with a reservoir formation
In order to re-establish both the intestinal continuity and the physiological function of the stomach to store food, the RY and the jejunal interposition reconstruction have been combined with the formation of a pouch reservoir as a stomach substitute. In addition, also colonic segments have been used for reservoir formations. Multiple different approaches have been described in the literature for the formation of a reservoir, several of them evaluated in RCTs.
Roux-en-y with pouch
RCT-evaluated reconstructions include the formation of a J-pouch [28, 29], a O-pouch , a S pouch , and an aboral pouch . The formation of a J-pouch involves a side-to side enteroenterostomy of the jejunum and a prolonged jejunal stump all the way to the esophago-jejunostomy with a total length of 15–20 cm (Fig. 12.4a). The O-pouch differs from the J-pouch in that the entero-enterostomy is not extended completely to the esophago-jejunostomy (Fig. 12.4b). The S-pouch is formed by accomplishing two enteroenterostomies at the end of the ascended jejunum (Fig. 12.4c). The aboral pouch is formed by fashioning, instead of a simple end-to-side Y-anastomosis of the afferent and efferent jejunal limbs, a long (15 cm) side-to-side antiperistaltic jejunojejunostomy (Fig. 12.4d).
Fig. 12.3. Reconstruction following total gastrectomy. a Schematic drawing of Roux-en-Y reconstruction, b) Schematic drawing of jejunal interposition, c) Schematic drawing of jejunal interposition with pouch
Jejunal interposition with pouch
Several duodenal passage-preserving reconstruction techniques including the formation of a pouch have been described, the earliest dating back to the 1950s [33, 34]. Only one reconstruction technique, the J-pouch combined with jejunal interpositions has also been evaluated by RCTs (Fig. 12.3c).
The idea of using the ileo-cecal valve as a substitute for the cardiac sphincter has first been published by Lee  and Hunnicutt . Both authors used an interposition of the terminal ileum and the cecum to bridge the gap after total gastrectomy. This technique is the only one published until today which attempts to include an anatomic barrier between the neo-stomach and the esophagus to prevent bilio-pancreatic reflux. In addition, the colonic segment by nature functions as a kind of reservoir due to its larger diameter when compared to a simple jejunal interposition. No data from randomized controlled studies in humans is available. Nonetheless, data from mini-pigs after distal resection  and prospective and retrospective studies on patients after total gastrectomy [22, 38] indicate a good functioning of the ileo-cecal valve as an antireflux barrier. Nevertheless, the technically demanding and thus morbidity-prone operation has not been evaluated in RCTs.
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