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Pouch creation improved long-term functional and nutritional outcomes after total removal of the stomach with no increase in perioperative morbidity, researchers in Singapore reported.

Their systematic review and meta-analysis examined 17 randomized trials and 8 observational studies, involving 1,621 participants, and looked at outcomes associated with pouch versus no pouch creation, including quality of life (QoL) 2 years after compete gastrectomy.

Besides a longer operating time, the meta-analysis found pouch construction had no adverse impact on perioperative outcomes, Jimmy Bok-Yan So, MBChB, MPH, of National University Singapore, and colleagues wrote in .

The procedure was associated with an increased operating time of 259.3 versus 235.8 minutes for a weighted mean difference (WMD) of 23.5 (95% CI 9.8-37.2), but not with longer hospitalization. There were no differences in overall post-surgical complications, including anastomotic leak and abdominal abscess, the authors noted.

So's group said the findings confirm those of previous meta-analyses, and that pouch creation should be considered the post-gastrectomy procedure of choice.

"Total gastrectomy is currently associated with significant morbidities, a reduced postoperative QoL and impaired nutrition, thus reconstruction procedures that mitigate these problems remain an unmet clinical need," they wrote. "Apart from a longer operating time, we did not find any evidence that pouch reconstruction procedures adversely impact perioperative outcomes."

The authors noted that the benefits of pouch construction have not been not fully determined. The 2014 Japanese Gastric Cancer Association recommended Roux-en-Y esophagojejunostomy, jejunal interposition, and the more recently introduced double-tract method as acceptable techniques for restoring of the alimentary tract, but cautioned that the full functional benefits of pouch formation have yet to be established.

A simple Roux-en-Y remains the current standard technique. While scintigraphic emptying studies have shown that pouch construction provides greater storage capacity, increases meal transit time, and assumes some of the metabolic functions of the stomach, whether these translate to improved nutrition and better patient outcomes is not clear.

Manometric studies have that found pouches may trigger or contractions, and possibly cause reduced food intake and postprandial reflux, emesis, and epigastric discomfort.

And case studies have suggested that the short-term advantages of a pouch can compared with the gradual increase in food capacity as the anastomosed jejunum in non-pouch reconstruction dilates. Also, pouches have been reported to weaken 1 or 2 years post-gastrectomy, resulting in severe reflux and abdominal distension.

For the current study, the authors reported that, in the period following surgery, pouch formation significantly reduced the risk of dumping syndrome at both 3 to 6 months (8.1% versus 32.4%, risk ratio 0.36, 95% CI 0.21-0.60) and 12 to 24 months (2.8% versus 23.6%. RR 0.27, 95% CI 0.16-0.46).

The functional advantages of pouch reconstruction persisted at up to 2 years, with pooled data indicating considerably lower risks of esophagitis and heartburn (63% relative reduction), dumping syndrome (73% relative reduction), and food intake disturbance (50% relative reduction).

Nutritional indicators were also notably higher in pouch recipients at 12 to 24 months. Albumin levels were 40.5 versus 37.9 g/L (WMD 2.59, 95% CI 1.35-3.84) and BMI was 22.2 versus 20.9 (WMD 1.28, 95% CI, 0.61-1.94).

The authors pointed out that their findings parallel those of two previous meta-analyses in and , which found significant improvements in QoL with no increased morbidity after pouch creation.

While pouch size appears to influence , the optimal dimensions of the post-gastrectomy pouch construct remain a point of contention. A recommended adopting a 15-cm pouch design, the authors noted.

Study limitations included considerable inter-study variability and the infrequent reporting of QoL outcomes across studies. "This, coupled with evidence of between-study heterogeneity, underscores the need for future studies to rigorously evaluate QoL outcomes using similar validated questionnaires," the authors wrote.

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