In Japan, the Billroth I and Billroth II operations have been used for reconstruction after a distal gastrectomy for gastric cancer. However, a Roux-en-Y reconstruction is increasingly performed to prevent duodenogastric reflux. We herein discuss the indications for Roux-en-Y in gastric surgery and review the literature to determine its advantages and disadvantages. Indications for Roux-en-Y reconstruction after a distal gastrectomy are: (a) When the primary lesion has directly invaded the duodenum or head of the pancreas, the Billroth I operation is likely to result in local recurrence near the anastomosis; (b) in addition, the Billroth I operation is not indicated after a subtotal gastrectomy due to an unacceptable anastomotic tension; reconstruction using a nonphysiological route is therefore preferred. The advantages of Roux-en-Y reconstruction after a distal gastrectomy include a reduction of reflux gastritis and esophagitis, a decreased probability of gastric cancer recurrence, and a reduction in the incidence of surgical complications such as ruptured suture lines. The disadvantages of Roux-en-Y reconstruction include the possible development of stomal ulcer, an increased probability of cholelithiasis, increased difficulty with an endoscopic approach to the ampulla of Vater, and the possibility of Roux stasis syndrome. The principal advantage of a Roux-en-Y reconstruction is that it is less likely than the Billroth I operation to result in duodenogastric reflux. Roux-en-Y reconstruction or Billroth I operation can only be selected after considering their respective advantages and disadvantages.
Patients develop anxiety before undergoing gastroscopy. By removing such distressing feelings, patients are more likely to experience gastroscopy more smoothly. This study was designed to examine changes in anxiety levels in patients undergoing gastroscopy and the effect of an optimal soothing environment (OSE) as a new nonpharmacological intervention to reduce patient anxiety prior to gastroscopy. During a 6-month period, 50 outpatients referred for gastroscopy were randomly assigned to two groups (control group, n = 24 patients; OSE group, n = 26 patients). This study was performed at the digestive endoscopy service of a 150-bed acute care hospital in Japan. The patient anxiety was assessed using the Face Scale score. Pre- and postprocedural systolic blood pressures were measured and values were compared with blood pressure upon arrival at the hospital. The tools for an OSE, including a safe essential oil burner with lavender essential oil and a digital video disk program entitled "Flow" manufactured by NHK (Japan Broadcasting Corporation) software, were provided to patients in the waiting room before gastroscopy. The score for self-assessed anxiety level just before gastroscopy was significantly higher than that on arrival at the hospital but returned to baseline after gastroscopy in the control group, whereas the score did not increase before starting gastroscopy in the OSE group. Systolic blood pressure measurements just before and after gastroscopy were significantly higher than those on arrival at the hospital and the baseline values in the control group, whereas it was not increased before starting gastroscopy in the OSE group. Providing an OSE before and during gastroscopy is useful to minimize patient anxiety regarding experiencing a gastroscopy. This nonpharmacological method is a simple, inexpensive, and safe method of minimizing anxiety before and during gastroscopy.
On the basis of the introduction of new technique using pigs, we believe that this procedure is useful for intramucosal carcinoma, which exceeds the standard indication for endoscopic mucosal resection, and for carcinoma invading the submucosa without lymph node metastasis.
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