Optimal gastric pouch reconstruction post-gastrectomy

Background. Gastric pouches have the potential to improve nutrition following total gastrectomy, compared with standard reconstruction. However, a consensus view of clinical benefit is not available, at least partly due to a lack of standardization of pouch design or size. This study was undertaken to identify optimal conditions for pouch design. Methods. A mathematical model was established and a porcine model constructed to evaluate the pressure/volume dynamics of the pouch. A "J" pouch was constructed at anastomotic lengths of 5, 10, 15, and 20 cm. Each pouch was distended with saline and the pressure/volume relationship established. Results. Mathematically, increasing the anastomotic length of the pouch to 15 cm increases the volume significantly; thereafter, there is minimal benefit of increasing the pouch length further. For smaller pouches (5 and 10 cm) a 350-to 400-ml volume (approximate meal volume in the elderly) is never achieved until higher pressures (45 cmH O) are applied. However, in the larger pouches (15 and 20 cm) a 350-to 400-ml volume is readily achieved at basal pressures of 15 cmH O. Conclusion. Smaller pouches never achieve adequate volumes at basal pressures; accordingly, it is unlikely that they will lead to any clinical benefit. Further in-vivo studies should therefore be based upon 15-cm pouch designs.