Summary of data from clinical trials comparing reconstructions after total gastrectomy

E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)

Reconstruction with or without a reservoir

A meta-analysis identified 13 RCTs (search until October 2008) addressing this question [39]. Nine RCTs compared Roux-en-Y reconstruction with (PRY) and without pouch (RY). Not all trials reported on all analyzed parameters. Seven RCTs could be combined for the analysis of morbidity or mortality. No significant difference could be shown for PRY vs. RY (187 vs. 200 patients). Operation time (3 RCTs, 58 vs. 44 patients) and hospital stay (two RCTs, 34 vs. 32 patients) did not increase significantly in PRY vs. RY. Dumping syndrome was significantly lower in PRY vs. RY 6 months (2 RCTs, 33 vs. 29 patients) and 12 months postsurgery (4 RCTs, 58 vs. 51 patients). Reflux was significantly lower in patients after PRY vs. RY 12–15 months postsurgery (2 RCTs, 19 vs. 18 patients). A tendency towards better food intake (measured as > or < than 50% of preoperative value) for PRY was observed at 3 and 6 months, while food intake was significantly better in PRY vs. RY at 12–15 months postsurgery (3 RCTs, 42 vs. 32 patients). Concerning the quality of life two RCTs used the same score and could be combined. No difference was detected when all patients were analyzed at 6, 12, and 24 months (2 RCTs, 72/52/35 vs. 66/46/33 patients). Nevertheless, both studies independently described significant differences in favor of a pouch at 24 and 30–60 months. If only patients with R0 resection in one trial and 5-year survival of the other trial were combined, a significantly better quality of life was achieved in RYP vs. RY at 12 and 24 months (2 RCTs, 33/22 vs. 29/22 patients).

Gastric cancer. Principles and practice (2015) 12.4

Fig. 12.4. Roux-en-Y reconstruction with a reservoir formation. a Schematic drawing of a J-pouch, b) Schematic drawing of a O-pouch, c) Schematic drawing of a S-pouch, d) Schematic drawing of an aboral-pouch

Four RCTs compared jejunal interposition with (JPI) and without (JI) pouch. Due to heterogenously reported parameters a meta-analysis could only be performed for mortality, which showed no significant difference between JPI vs. JI (3 RCTs, 67 vs. 46 patients).

Preservation of the duodenal passage

Nine RCTs compared duodenal preserving reconstructions (DP) by jejunum interposition with and without pouch to nonduodenal preserving (NDP) Roux-en-Y reconstruction with and without pouch. These studies have been jointly analyzed in a meta-analysis (search until May 2012) [40]. Four RCTs could be analyzed for morbidity differences between DP and NDP (148 vs. 153 patients), and 5 RCTs could be analyzed for mortality differences (169 vs. 176 patients), resulting in no statistical difference between the 2 procedures. Operation time was significantly longer in DP vs. NDP (6 RCTs, 207 vs. 222 patients). Body weight could be analyzed in 2 studies (DP 83 vs. NDP 84 patients) at 3 and 6 months, showing a statistically significant increased weight in DP. Four studies statistically described body weight development at different later time points, precluding a formal meta-analysis. Nevertheless, each study reported no statistical difference at time points > 12 months postsurgery. Bilio-pancreatic reflux was analyzed in 2 and for 1 time point in 3 RCTs, showing no difference between DP and NDP at 3, 6, 12 and 24 months (20/20/30/19 vs. 22/22/32/21 patients). The incidence of dumping syndrome was significantly lower in DP vs. NDP at 3, 6, and 24 months (3 RCTs, 95/95/95 vs. 102/102/101 patients), but not at 12 months with the inclusion of one more trial (4 RCTs, 105 vs. 112 patients). Of note, when only RCTs which included a pouch were analyzed, no statistical difference between DP vs. NDP could be detected (2 RCTs for 3, 6, 24 months with 20/20/19 vs. 30/30/28 patients and 3 RCTs for 12 months with 30 vs. 50 patients). Quality of life could not be analyzed in a combined fashion due to different measurement scales. Of 5 RCTs, only 1 study showed an improved quality of life at 6 months in DP vs. NDP (24 vs. 24 patients), while all others reported no statistical difference at this, earlier, and later time points (up to 60 months).

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