J Korean Surg Soc 2010;78:290-297 DOI: 10.4174/jkss.2010.78.5.290 원 저 장막침윤이없는위암에서하부식도조임근보존전체위절제술후공장낭간치술 가톨릭대학교의과대학외과학교실 김동진ㆍ허훈ㆍ전해명ㆍ김욱 Near-Total Gastrectomy Preserving the Lower Esophageal Sphincter Followed by Jejunal Pouch Interposition as a Treatment for Upper Gastric Cancer Dong Jin Kim, M.D., Hoon Hur, M.D., Hae Myung Jeon, M.D., Ph.D., Wook Kim, M.D., Ph.D. Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea Purpose: Conventional total gastrectomy with Roux-en-Y esophagojejunostomy has certain limitations such as insufficient food reservoir and malabsorption of nutrients. Therefore, we performed reconstruction of the jejunal pouch interposition (JPI) after near-total gastrectomy preserving the lower esophageal sphincter (LES). We compared the technical feasibility, safety, and surgical outcome of this operation with conventional total gastrectomy accompanying with Roux-en-Y esophagojejunostomy. Methods: From April 2003 to October 2005, 15 LES-preserving, near-total gastrectomies with JPI (LES-JPI group) were performed. The clinical features and surgical outcomes were retrospectively compared with 17 cases of conventional R-Y esophagojejunostomy. Statistical analysis was performed using Fisher s exact test for categorical data and an unpaired t-test for continuous data. Results: Clinicopathological features of the LES-JPI and R-Y groups did not show differences excepting patient age (50.8±5.8 years vs. 62.8±12.4, respectively; P=0.002) and the depth of tumor invasion (T1-T2; 11 4 vs. 5 12; P=0.032). The operative outcomes for the two groups significantly differed in terms of operation time (676 vs. 484 min; P=0.008) and blood loss (424 vs. 336 ml; P=0.006). Postoperative gastrofiberscopic examination of all LES-JPI patients showed no esophageal reflux or strictures and intact LES. In addition, the LES-JPI group did not experience swallowing difficulty or stricture. Conclusion: LES-preserving total gastrectomy with JPI is a feasible and safe procedure for patients with upper gastric cancer. (J Korean Surg Soc 2010;78:290-297) Key Words: Gastric cancer, Lower esophageal sphincter, Jejunal pouch interposition 중심단어 : 위암, 하부식도조임근, 공장낭간치술 서 론 책임저자 : 김욱, 서울시영등포구여의도동 62 150-713, 가톨릭대학교성모병원외과 Tel: 02-3779-1175, Fax: 02-786-0802 E-mail: kimwook@catholic.ac.kr 접수일 :2009 년 10 월 26 일, 게재승인일 :2010 년 1 월 18 일 전체위절제술을시행한후현재가장많이이용되는재건술식인 Roux-en-Y 식도공장문합술은위가없어지고공장이십이지장과바로연결되지못하는우회때문에빈혈이생기고, 지방과질소대사이상으로인한영양장애와역류성식도염등의발생이주요문제점으로남아있다.(1) 290
Dong Jin Kim, et al:near-total Gastrectomy Preserving the Low Esophageal Sphincter 291 전체위절제술을보완하기위해 1952년 Hunt(2) 와 1962년 Lawrence(3) 는공장을측-측문합하여낭을만든후 Rouxen-Y식으로재건하였는데이는음식저류 (stasis) 와흡수장애의단점이있지만술후소화장애증상이경미하고, 체중감소가타술식에비해적다고보고되었다.(4) 이후전체위절제술후공장낭을이용한수술이수술후영양상태및역류증상을개선한다는보고들이있으나 (5,6) 이론적인장점에도불구하고기존수술방법에비하여수술시간이오래걸리고문합부의수가많아져합병증발생가능성이높아보편적으로이용되지는못하였다. 상부위암으로전체위절제술을시행할때식도주위림프절절제와충분한근위부절제연확보를위해하부식도괄약근 (lower esophageal sphincter, LES) 상부 2 3 cm를절제하는것이일반적이다. 그러나식도주위림프절전이가없거나또는가능성이적은 T1, 2병변의상연이 LES에서 3 4 cm 이상떨어진경우 LES를보존하게되면섭취한음식물의역류를줄일수있다. 또한, 공장낭을십이지장에바로연결하면서섭취한음식물의생리적경로를유지할수있어더욱효과적일 것으로기대하였다. 저자들은종양의상연이 LES에서 3 4 cm 떨어져있고장막침윤이없는경우, 전체위절제술후 15 cm 길이의공장낭을 LES가보존된식도와십이지장사이에끼워넣는술식을시행하여임상결과를보고하고자한다. Fig. 1. Proximal resection. Auto-purse string device is applied for proximal resection at a distance of 1.5 to 2.5 cm from the lower esophageal sphincter. Fig. 2. Jejunal pouch reconstruction. Jejunal pouch is reconstructed in a side-to-side manner, using a 100-mm GIA stapler. (A) Application of a GIA device. (B) Completion of a jejunal pouch. Fig. 3. Anastomosis. Jejunal pouch is anastomosed between proximal cardia and duodeneum. (A) An illustration. (B) An upper gastrointestinal contrast test.
292 J Korean Surg Soc. Vol. 78, No. 5 방법 2003년 4월부터 2005년 10월까지비교적장기간생존이예측되는 T1, T2 환자들중, 수술전내시경에서종양의위치가 LES에서최소 3 4 cm 떨어져있었던 15예를대상으로시행되었고, 개복하였을때장막침윤이의심되거나또는필요한경우림프절 1번, 2번에대하여동결절편을시행하여양성이면기존방식인전체위절제술과 Roux-en-Y 재건술식을시행하였다. LES 보존전체위절제술이기존의수술방법과다른점은식도부위를절제할때 auto-purse string을 angle of His의대만쪽을하방으로견인한상태에서 LES 하방약 2 cm 정도에서절제하는점이다 (Fig. 1). 공장낭간치술의재건방법은트라이쯔인대하방에서첫번째공장혈관을보존하면서 25 30 cm의공장분절을취한후, 반으로접어 100 mm, 80 mm GIA (US Surgical, Norwalk, CT, USA) 를절제연쪽으로삽입하여측-측공장낭을만든다 (Fig. 2). 만들어진공장낭을횡행결장막을통해이동한후근위부와원위부절단면을내강의크기에따라서 25 mm 에서 28 mm의 EEA (US Surgical, Norwalk, CT, USA) 를이용하여문합하였고 EEA 삽입부위는 GIA로봉합하였다 (Fig. 3). 이와같은술식이시행된 15예 (LES-JPI군) 의결과를동일기간에같은조건으로전체위절제술및기존의 Roux-en-Y 술식을시행한 17예 (R-Y군) 와임상병리학적특성, 술식에관한차이를후향적으로분석하였고, 이들환자를대상으로영양평가의지표로서체중변화, 총단백질, 알부민, prognostic nutritional index (PNI) 등을시행하였고, 이를 R-Y군에서의결과와비교하였다. 연하곤란과역류증상에대하여외래에서환자의증상호소에대하여조사하여추적검사기간동안증상이있었던경우를합병증이있다고판단하였으며협착에대해서는내시경소견을보고판단하였다. 평가기간은수술후첫 3개월동안은매달관찰하였고, 술후 1년까지는 3개월마다, 이후에는 1년마다환자를관찰하였다. 통계처리는 Fisher's exact test와 unpaired t-test를이용하였으며 P 값이 0.05 이하일때통계적으로의의가있다고하였다. 결과 1) 임상병리학적특성 (Table 1) 평균연령은 LES-JPI군이 50.8±5.8세, R-Y군은 62.8±12.4 세로양군간에의미있게차이가있었으며 (P=0.002), 수술 Table 1. Clinicopathological characteristics Factors JPI* group (n=15) R-Y group (n=17) P-value Age 50.8±5.8 62.8±12.4 0.002 Sex Male 7 8 0.982 Female 8 9 Resected margin Ow 2.3±1.4 2.4±2.6 0.877 Aw 7.3±3.3 7.4±3.9 0.935 Tumor size 4.56±3.17 5.81±3.13 0.266 Tumor location Upper 1/3 3 6 0.337 Middle 1/3 12 11 Retrieved nodes 38.1±21.1 30.5±14.9 0.244 Positive nodes 0.3±0.7 0.8±1.6 0.282 Depth of Invasion T1 11 5 0.032 T2 4 12 LN metastasis N0 12 11 0.337 N1 3 6 Histologic type Differentiated 7 11 0.305 Undifferentiated 8 6 TNM stage Ia 11 4 0.539 Ib 1 8 II 3 5 *JPI = jejunal pouch interposition; R-Y = roux-en-y; Ow = proximal resection margin; Aw = distal resection margin; LN = lymph node.
Dong Jin Kim, et al:near-total Gastrectomy Preserving the Low Esophageal Sphincter 293 후여명을고려하여젊은환자들에게주로시행되었다. 남녀비는 7:8과 8:9로차이가없었다. R-Y군의환자는모두개복수술이었으나 LES-JPI군은개복수술이 5명, 복강경술식이 9명이었다. 종양의위치는 LES-JPI군이분문부가 3명이었으며 12명은체부에위치해있었고 R-Y군에서는분문부가 6명, 체부가 11명이었다 (P=0.337). 절제림프절의개수는 LES-JPI군이 38.1±21.1개이고 R-Y군이 30.5±14.9개였고 (P=0.244) 전이림프절개수에서도 LES-JPI군이 0.3±0.7 개, R-Y군이 0.8±1.6개 (P=0.282) 로 TNM병기로 N1군이 LES-JPI군에서는 3명, R-Y군에서는 6명 (P=0.337) 이었다. 근위부절제연은 LES-JPI군이평균 2.3±1.4 cm이고 R-Y군은 2.4±2.6 (P=0.877) 이었고 2 cm 미만인경우가 6예가있었다. AJCC분류에의한병기로 LES-JPI군 II기가 3명, Ib가 1명, 나머지 11명은 Ia를보이고있었다. R-Y군에서는 II기가 5 명, Ib가 8명, 나머지 4명이 Ia였다. 재발이나사망은 R-Y군 Table 2. Operative outcomes Factor JPI* group R-Y group (n=15) (n=17) P-value Blood loss 676.7±181.1 484±191.2 0.006 Operation time 424.0±58.6 336.9±102.9 0.008 First flatus (POD ) 3.5±0.9 4.1±0.9 0.066 First soft diet (POD) 5.5±0.9 6.2±0.9 0.065 Hospital stay (days) 15.7±7.6 14.3±4.8 0.538 *JPI = jejunal pouch interposition; R-Y = roux-en-y; POD = post operative day. 에서수술후 2년째각각폐와뇌전이로 2명의환자가사망하였다. 2) 수술결과 (Table 2) 수술시간은 LES-JPI군이 424.0±58.6분으로 336.9±102.9 분인 R-Y군보다길었다 (P=0.006). 출혈량에있어서도 LES-JPI군이 676.7±181.1 ml로 484±191.2 ml인 R-Y군보다더많았다 (P=0.008). 수술후첫장가스배출시기및식이시작시점, 수술후재원일수에있어서는의의있는차이는없었다. 3) 조기및후기합병증 (Table 3) 수술후추적관찰중 2 년내연하곤란및위식도역류와 Table 3. Postoperative morbidity Complication JPI* group (n=15) R-Y group (n=17) P-value Early Leakage 2 0 0.212 SB obstruction 1 0 0.469 Late Swallowing difficulty 0 6 0.019 Reflux 0 5 0.046 Stricture 0 2 0.486 *JPI = jejunal pouch interposition; R-Y = roux-en-y; SB = small bowel; Managed by endoscopic balloon dilatation. Fig. 4. Comparision of perioperative changes in nutritional markers. The groups showed no statistically significant differences in terms of (A) total protein, albumin, or (B) prognostic nutritional index. P-values refer to the differences in the change of the nutritional markers from their preoperative level between the two groups.
294 J Korean Surg Soc. Vol. 78, No. 5 관련된조사에서전체적으로증상을호소한수에있어서 LES-JPI 환자들은 2년내연하곤란과식도역류증상을호소하는환자가없었으며의의있는통계학적인차이를나타내었다. 수술후추적관찰한내시경소견에서는 LES-JPI 환자에서협착을보인경우는없었으나기존술법으로시행한군의연하곤란을호소한환자중 2명에서식도공장문합부협착이보여수술후 3개월째에풍선확장술을시행하였다. 본연구에서의수술시행후조기합병증으로재수술을시행한경우가 LES-JPI 군에서 3예가있었는데 2예에서공장낭측문합부위및공장낭과십이지장의문합부누출로일차봉합술을시행하였고, 1예에서수술후장유착으로유착박리술을시행하였으므로실제로공장낭관련조기합병증은 2예에해당한다. 수술과관련된사망례는없었다. 4) 수술후영양지표및체중변화 수술후추적관찰하였던혈액검사에서는총단백수치, 알부민, PNI의수술후변화량에있어서별다른통계학적의의는없었다 (Fig. 4). 수술후 3년까지측정한체중감소율에있어서도 R-Y군과 LES-JPI군이각각 10.57 14.13%, 8.70 9.12% 으로 LES-JPI군에서수치는적었으나통계학적차이는없었다 (Fig. 5). Fig. 5. A comparison of the proportion of body weight loss relative to preoperative body weight. Postoperative weight loss in the LES-JPI group (8.70 9.12%) was lower than that in the R-Y group (10.57 14.13 %), the difference was not statistically significant. P-values refer to the differences in the change of the weight from their preoperative level between the two groups. 고찰 위암으로전체위절제술을시행한환자들은수술후한끼양의감소와식사횟수의증가, 소화불량및체중감소등을호소한다. 전체위절제술후가장흔한문합법인 R-Y 문합술로인해음식물의십이지장우회에따른철분, 지방, 칼슘, 카로틴등의흡수장애등이발생할수있다. 그외에식도-공장문합부협착이나역류증상이있는경우도드물지않아식도확장이나역류차단투약을하는예도많다.(1,7) 최근위암발생의변화를보면조기검진에의한조기위암의증가와함께상부위암도증가되는추세에있어이들환자에대해예외없이전체위절제술를시행하는것도재고해봐야할문제이다. 이렇듯환자들의장기생존이증가하고이에따른수술후삶의질에대한관심이높아지면서어떻게하면위를보존하면서암을근치적절제하느냐가관건이라할수있겠다. 이에 1990년대후반부터일본을중심으로한층발전된간치술이시행되고또한좋은결과들이보고되고있다. 이러한간치술에는자동문합기 (EEA, GIA) 의역할이매우큰데, 실제적으로수술시간이현저히단축되고, 수기문합보다문합부누출등의합병증이현저히감소되었고, 특히영양학적인장점들이많이보고되고있다.(5) 이에저자들은과거부터위절제후공장낭을이용한간치술을시행하여왔고원위부위절제후공장낭을이용한간치술이 1시간정도수술시간이더걸리고, 수술후초기에위배출시간이지연되는경향이있지만, 몸무게를포함한영양학적인면을고려할때, 장기생존이기대되는제 I, II기위암환자에게적용될수있다고보고하였다.(8) 이번연구에서는이술식을전체위절제술나근위부위절제에도시행하였는데특히이경우에서십이지장과문합할수있는전제조건이위절제시에 LES를반드시보존하여식도역류를예방해야하는점이었다. 수술적응도한계가있어중-상부위암에서식도주위의완전한림프절절제가필요한 T3인경우는혈액공급의저하로인한문합부누출이나협착의위험성때문에배제하였고, T1, 2인경우에도림프절 1번은미주신경절단과함께완전히절제하였으나, 림프절 2번은수술시 angle of His 부위에한정하여식도상부쪽은보존하도록하였다. 또한이경우의림프절은반드시동결절편검사를통해전이여부를확인하여만약양성이면예정된술식을기존의 R-Y로변경하도록계획하였으나
Dong Jin Kim, et al:near-total Gastrectomy Preserving the Low Esophageal Sphincter 295 한예에서도이런경우는발생되지않았다. LES-JPI 술식은기존의 R-Y 수술과비교하여여러가지기대효과가있다고생각되는데, 첫째로식도와의문합에서발생될수있는협착과역류가 LES가보존됨으로써예방된다. 실제로기존 R-Y 술식의수술후초기에가장문제가되는것은협착으로 Takeyoshi 등 (9) 은원형자동문합기를이용하여식도공장문합을하였던경험에서 324명의환자중 16명 (4.9%) 에서문합부협착이있었다고보고하였다. 저자들의경우환자의증상과내시경소견을비교하였을때기존의식도공장문합에서는 2예에서협착으로풍선확장술이시행되었으나, LES-JPI 술식이시행된환자들의경우술후협착이나역류로인한증상을호소하는경우는없었으며또한술후 6개월및 1년에시행된위내시경하에서도이러한소견은전혀발견되지않았다. 식도역류는 Roux limb의길이가 40 cm이면담즙이나췌장액의역류를줄일수있다고보고되어있지만,(10) 그럼에도불구하고역류증상을호소하는환자가드물지않아 Collard와 Romagnoli(11) 는전체위절제술을시행한환자에서는 17명중 5 명에서 Roux-limb에서담즙역류가보였다고보고하였다. 그러나저자들의술식은 LES 기능이정상적으로유지되기때문에공장낭의길이를 15 cm로해서바로십이지장과연결해도식도로의역류가발생되지않았다. 본연구에서역류와관련하여압력측정 (manometry) 을이용한 LES 압력이나 ph 측정등의정밀검사가시행되지않아보존된 LES의정확한기능이분석되지는않았다는제한점이있으나증상이나내시경적인검사에서는정상기능에가까웠음이확인되었다. 둘째는공장낭을이용한위의음식물저장기능을늘일수있다는것이다. 물론기존의 R-Y 술식을받은환자들도일정기간이지나면술전과같은양의식사가가능하게되지만간혹음식물이하부소장으로빠르게이동하면서연동운동에의한통증및덤핑증상이계속될수있다. Herfarth 등 (12) 은공장낭이섭취한음식을십이지장으로이동시키는시간을지연시켜위유문의역할을대신함으로서덤핑증후군을줄일수있고, 소화와흡수를위한공간을확보할수있다는장점을강조하였다. 또다른보고에서공장낭간치술을시행한경우에서식사량의증가및식사빈도를줄일수있는점들은증명되었다.(13) 저자들의경우에서도환자들의내시경이나위장관조영술등을통해충분한저장공간으로의공장낭을관찰할수있었지만, 실제로정확한평가를위해서는수술후식사량이나증상과관련된지표로설문을작성해서비교할필요가있겠다. 셋째 는공장낭을십이지장에직접연결하여음식물의식도-공장낭-십이지장의생리적인흐름을유지하여, 영양의흡수및소장의연동운동의방향에영향을미침으로서긍정적인효과를기대할수있다. R-Y 술식을시행한이후에발생하는담즙역류및저류는십이지장으로부터시작되는전기신호가차단되기때문이며이로인하여발생하는느린파동이나역류성파동이그원인으로간주된다.(14,15) 그동안의여러보고들은섭취한음식물의생리적경로의유지를통하여위장관의근신경전도를정상적으로진행시키며, 환자들의영양상태및수술후삶의질의향상에도움을줄수있다고보고하였다.(16-19) 위에언급한세가지측면들은각각의의미보다는서로상호작용하여위절제후나타나는증상의완화와체중을포함한영양지표의향상에서더욱큰의미가있겠다. Nozoe 등 (6) 은기존루와이수술과공장낭간치술과의영양지표에대한비교에서수술후 1년째의체중과혈청알부민이공장낭간치술을시행받은환자가유의하게높았다고보고하였다. 저자들의경우에는수술후 3년까지측정한체중감소율이기존의 R-Y 술식의 10.57 14.13% 에비해 8.70 9.12% 로수치는적었지만통계학적인의의가없어좀더많은경험이필요할것으로보인다. 수술방법에관해서는보고자에따라공장낭길이나모양등에서차이점이있지만저자들의방법을기술하여보면공장낭은공장분절을트라이쯔인대에서첫번째공장혈관을보존하면서그원위부의 30 cm의공장분절을취하는데, 공장혈관을충분히취하는것이공장낭의혈관공급을유지하는데가장중요하다. 즉공장낭을만들면장간막반대측의일부에혈액공급이거리상멀어순환장애가나타나부분적허혈이발생될수있는데, 이런경우에는공장낭과잔위와의문합을즉시시행하지않고공장과공장을먼저문합하고나중에공장낭의혈관공급이회복된상태를관찰한후, 색깔이변한곳을변연절제하여공장낭과문합하면안전하다. 또한공장장간막의분리를최소화해야운동신경섬유의손상을최대한줄여술후음식저류가예방될수있다. 또한하부식도괄약근보존에있어문제가되는것은병변부로부터근위부절제연을확인하는것이다. 저자들의경우근위부절제연은평균 2.3 cm (1 5 cm) 이지만 2 cm 미만인경우도조기위암에서 5예가있었지만현재까지문합부재발은발생하지않았다. 그러나수술시반드시절제연의동결절편검사를통해확인이필요하겠고절제연의길이가충분하지못한경우기존술식으로전환하
296 J Korean Surg Soc. Vol. 78, No. 5 는것이좋겠다. 수술후발생가능한합병증은두술식모두동일하지만합병증중문제가되는것은장관내출혈로서이를예방하기위해서는공장낭의측측문합부위의출혈부위를모두결찰해야하고, 공장낭을통해자동문합기로십이지장과문합시공장내강이좁은경우무리하게밀어넣으면점막이밀리면서출혈이나혈종이발생할수있기때문에주의해야한다. 또한 LES-JPI 술식의경우문합부가많고, 특히공장낭이나 LES 부위의혈관공급장애로문합부누출의기회가기존술식에비해많이노출되어있다. 저자들의경우두군모두출혈은없었지만 LES-JPI에서공장낭측측문합부누출이 2예에서발생되어재수술로일차봉합하였다. 이외에공장낭의지속적인팽창과음식저류로인한세균증식으로공장낭염 (pouchitis) 이발생할수있으며궤양의발생이보고되었지만,(20,21) 저자들의경우현재까지이러한합병증은발생되지않았다. 결 저자들이시행한 LES-JPI 술식은수술시간이더걸리고출혈량이많은것으로나타났으며영양학적인측면에서도알부민및총단백수치, 체중손실에있어통계적우월성을획득할수는없었다. 하지만 LES-JPI 환자들의연하곤란이나역류증상은줄어드는것으로나타났다. 앞으로장기적인추적결과와전향적연구가필요하겠지만 LES를보존하면서음식물을십이지장을통해내려가게한다는이론적우월성을생각한다면, 수술후합병증발생이낮은환자에서장기생존이기대되는제 I, II기위암환자에게새로운수술방법으로적용될수있을것이다. 론 REFERENCES 1) Bradley EL 3rd, Isaacs J, Hersh T, Davidson ED, Millikan W. Nutritional consequences of total gastrectomy. Ann Surg 1975;182:415-29. 2) Hunt CJ. Construction of food pouch from segment of jejunum as substitute for stomach in total gastrectomy. AMA Arch Surg 1952;64:601-8. 3) Lawrence W Jr. Reservoir construction after total gastrectomy: an instructive case. Ann Surg 1962;155:191-8. 4) Scott HW Jr, Law DH 4th, Gobbel WG Jr, Sawyers JL. Clincal and metabolic studies after total gastrectomy with a Hunt-Lawrence jejunal food pouch. Am J Surg 1968;115:148-56. 5) Takeshita K, Sekita Y, Tani M. Medium- and long-term results of jejunal pouch reconstruction after a total and proximal gastrectomy. Surg Today 2007;37:754-61. 6) Nozoe T, Anai H, Sugimachi K. Usefulness of reconstruction with jejunal pouch in total gastrectomy for gastric cancer in early improvement of nutritional condition. Am J Surg 2001; 181:274-8. 7) Stael von Holstein C, Ibrahimbegovic E, Walther B, Akesson B. Nutrient intake and biochemical markers of nutritional status during long-term follow-up after total and partial gastrectomy. Eur J Clin Nutr 1992;46:265-72. 8) Kim W, Jeon HM, Hur H, Lee JH, Won JM. Jejunal pouch interposition after distal gastrectomy in patients with gastric cancer. J Korean Gastric Cancer Assoc 2004;4:242-51. 9) Takeyoshi I, Ohwada S, Ogawa T, Kawashima Y, Ohya T, Kawate S, et al. Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique. Hepatogastroenterology 2000;47:1026-9. 10) Besson A. The Roux-Y loop in modern digestive tract surgery. Am J Surg 1985;149:656-64. 11) Collard JM, Romagnoli R. Roux-en-Y jejunal loop and bile reflux. Am J Surg 2000;179:298-303. 12) Herfarth C, Stern J, Buhl K. Small intestine pouches as a therapeutic principle in stomach and large intestine replacement. Z Gastroenterol 1988;26:397-403. 13) Miyoshi K, Fuchimoto S, Ohsaki T, Sakata T, Ohtsuka S, Takakura N. Long-term effects of jejunal pouch added to Roux-en-Y reconstruction after total gastrectomy. Gastric Cancer 2001;4:156-61. 14) Woodward A, Sillin LF, Bortoff A. Migrating myoelectric complex and jejunal slow-wave propagation after Roux gastrectomy in dogs. Dig Dis Sci 1993;38:1073-8. 15) Karlstrom LH, Soper NJ, Kelly KA, Phillips SF. Ectopic jejunal pacemakers and enterogastric reflux after Roux gastrectomy: effect of intestinal pacing. Surgery 1989;106:486-95. 16) Zherlov G, Koshel A, Orlova Y, Zykov D, Sokolov S, Rudaya N, et al. New type of jejunal interposition method after gastrectomy. World J Surg 2006;30:1475-80. 17) Miholic J, Meyer HJ, Muller MJ, Weimann A, Pichlmayr R. Nutritional consequences of total gastrectomy: the relationship between mode of reconstruction, postprandial symptoms, and body composition. Surgery 1990;108:488-94. 18) Del Gaudio A, Marzo C. Interposition of the first jejunal loop for reconstruction after total gastrectomy. Int Surg 1991;76: 91-7. 19) Schwarz A, Buchler M, Usinger K, Rieger H, Glasbrenner B, Friess H, et al. Importance of the duodenal passage and pouch volume after total gastrectomy and reconstruction with the Ulm pouch: prospective randomized clinical study. World J Surg 1996;20:60-6. 20) Yasoshima T, Denno R, Ura H, Mukaiya M, Yamaguchi K, Hirata K. Development of an ulcer in the side-to-side anasto-
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