A Comparative Study of Japanese and American Gastric Dimensions HARRY S. GOLDSMITH, M.D.,* HIROSHI AKIYAMA, M.D.t
A comparative study between Japanese and Americans was carried out to determine gastric characteristics of the two groups, since Japanese appear to allow easier gastric transposition to the neck. Japanese were found to have a longer and more mobile stomach, but in the vast majority of Americans an esophagogastric anastomnosis in the neck is possible following an extensive Kocher maneuver.
IN SPITE OF DISTRESSINGLY poor survival statistics following surgery for esophageal carcinoma, many surgeons continue to believe that there is an important place for surgery in this disease; if not for cure, certainly for palliation. Surgeons in the Far East have reported little difficulty in mobilizing the intact stomach into the neck in order to reestablish gastrointestinal continuity following esophagectomy.1 However, most American surgeons have not exhibited a routine surgical ease in performing this maneuver. This apparent discrepancy in the technical skill required for gastric transposition to the neck has raised the question as to whether there is something different between the stomach of a Japanese as compared to an American. The purpose of this study was to address this possibility by measuring the physical dimensions of the stomach of these two racial groups. Materials and Methods
Seventy patients were included in the study; half from the United States (Philadelphia and Hanover) and the remainder from Japan (Tokyo). There were 20 males and 15 females in the Japanese group and 17 males and 18 females in the United States group. The individuals studied were random autopsy specimens who had died from various medical and surgical conditions which had not involved the esophagus, stomach, or diaphragm. * Professor of Surgery, Dartmouth Medical School. t Chief, Department of Surgery, Toranomon Hospital, Tokyo, Japan. Reprint requests: Harry S. Goldsmith, M.D., Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire 03755. Submitted for publication: May 9, 1979.
From The Departments of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire and Toranomon Hospital, Tokyo, Japan
Six gastric measurements were made in order to assess the physical characteristics of the oriental and occidental stomach. These measurements (in centimeters) included the following: 1) the distance from the sternal notch to the hyoid bone; 2) the distance from the costal angle to the sternal notch; 3) the length of the lesser curvature of the stomach; 4) the length of the greater curvature of the stomach; 5) the distance between the pylorus, as measured at the pyloric vein, and the diaphragm after the duodenum had undergone an extensive Kocher maneuver which required the mobilization of the entire second portion of the duodenum and the head of the pancreas as far medially as the vena cava; 6) the distance between the costal angle and the cardioesophageal junction. A seventh measurement in the study was the height of the patient (Figs. 1 and 2). Results
Japanese men and women, as expected, were found to be shorter than their American counterparts (Figs. 3 and 4). The Japanese group also demonstrated a shorter distance between the costal margin and the sternal notch which simply reflected the shorter longitudinal thoracic length consistent with their overall decrease in total body height. Necks of Japanese and Americans were found to be relatively comparable as measured by the distance from the sternal notch to the hyoid bone. The distance between the costal angle and the cardioesophageal junction showed a slight increase in Japanese men and women as compared to Americans. The significance of this measurement appears of little importance other than to raise the possibility that mobilizing the stomach into the neck in a Japanese patient requires a slightly longer distance if placed in
0003-4932/79/1200/0690 $00.70 © J. B. Lippincott Company
690
Vol. 190 . No. 6
COMPARISON OF GASTRIC DIMENSIONS
691
FIGS. I and 2. Illustrations of the various gastric dimensions measured in the study.
190
ANGLE TO NOTCCH
BODY HEIGHT
LESSER-
GREATER CURVATURE
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FIG. 3. Individual gastric measurements of Japanese and American subjects. Stipled line indicates mean measurements. Eighteen Japanese had their pylorus elevated to or above diaphragm compared to seven Americans.
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GOLDSMITH AND AKIYAMA
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Ann. Surg. * December 1979
esophagogastric anastomosis. This feat would be very difficult, if not impossible, in an American who characteristically is taller than his Japanese counterpart. It must be stressed, however, that in those Americans in this study whose pylorus could not be brought close to the diaphragm, it was still possible in the majority of these individuals to mobilize the stomach into the neck.
-
55 50_ 45_ 40_
35 30_ 25 20a 15 -
Discussion The large bowel which frequently has been used to replace a resected esophagus is always bacterially 01 contaminated regardless of the thoroughness of a 1CI preoperative antibiotic bowel preparation. Additionally, its use as an esophageal replacement requires 0 BODY ANGLE LESSER GREATER multiple anastomoses; a colocolostomy, a cologasHEIGHT TO NOTCH CURVATURE CURVATUREE trostomy and a coloesophagostomy. Another serious ,10 limitation of the large bowel is the awareness that 5% 1r9 of all colons have an inadequate arterial blood supply and 15% a deficient venous out-flow tract when used 12F as an esophageal substitute.2 These serious drawbacks E in a colon bypass following esophagectomy has led to 10F many serious postoperative complications includ8 ing death. CD The major problems associated with a colon bypass z 2 in increasing interest in the use of a reversed resulted IJ gastric tube made from the greater curvature of the 4 stomach as originally described by Gavriliu3 and co popularized by Heimlich.4 This tube is antiperistaltic L1 R1 and requires an extensive suture line to close the deMIDIPOIN NOTCH PYLORIC TO HYOID VEIN fect along the greater curvature of the stomach and to make the gastric tube itself. It is reasoned by the FIG. 4. Range and mean of gastric measurements of subjects authors that if a tube made from a portion of the studied. Note restricted pyloric mobility of Americans compared to Japanese. 0: Japanese males (20). A: Japanese females (15). stomach can be a suitable substitute for an esophagus, 0: U.S. white males (17). A: U.S. white females (18). why wouldn't an isoperistaltic stomach be easier to construct and be superior physiologically when used for a retrosternal or a subcutaneous position relative to this purpose. the same maneuver in an American. Anastomosing the isoperistaltic stomach to the The Japanese were found to have a longer greater cervical esophagus allows complete resection of the curvature of the stomach with the Americans having a thoracic esophagus which is highly desirable because longer lesser curvature. Both these measurements have of the known propensity of an esophageal malignancy significant implications when one is attempting to to spread by intramural extension. Another positive lengthen the stomach for subsequent anastomosis to aspect in using the isoperistaltic stomach as an the cervical esophagus. Of greater importance in gastric esophageal substitute is that its construction allows mobilization is the distance that remains between the for the excision along the proximal half of the lesser pylorus (as measured from the pyloric vein) and the curvature of gastric lymph nodes which frequently diaphragm following an extensive Kocher maneuver. harbor metastatic tumor from the primary esophageal It was found that the Japanese could have their pylorus neoplasm. elevated up to, and even above, the diaphragm with If an anastomotic disruption occurs in the neck follittle difficulty in comparison to Americans in whom lowing gastric transposition, it usually is not the result there is great variability in accomplishing this of vascular compromise, but of technical error because maneuver. One of us (H.A.) has shown that in an of the extensive intramural vascular network supplied occasional Japanese patient, it is not even necessary by the right gastric and the right gastroepiploic arteries and veins. This vast vascular network is not present to do a Kocher maneuver in order to perform a cervical -
-
-
I
1
w
3
6
-
w
Vol. 190 * No. 6
COMPARISON OF GASTRIC DIMENSIONS
in a reversed antiperistaltic gastric tube. Fortunately, any anastomotic leak in the cervical area results in only a cutaneous fistula as opposed to the catastrophe that can occur when there is disruption of an esophageal anastomosis in the chest which invariably leads to empyema and often death. This study which has compared the physical dimensions of American and Japanese stomachs indicates that there are gastric characteristics which allow easier gastric transposition into the neck in Japanese patients. It must be reemphasized, however, that it was possible in approximately 75% of the Americans in this study to bring the stomach into the neck following an extensive Kocher maneuver. In the other 25%, a Kocher maneuver was not sufficient to accomplish this, but there are several maneuvers which are possible if one were performing surgery on these individuals which would allow the construction of a gastroesophageal anastomosis in the neck. This first maneuver is to place the stomach in the chest along the route which follows the shortest distance to the neck. The shortest distance between the peritoneal cavity and the cervical region is by way of the posterior mediastinum with the retrosternal and subcutaneous positions, respectively, being longer in length. A second maneuver which helps one compensate in those patients whose stomachs appear too short for a
693
cervical anastomosis is to suture the gastric segment under tension along the posterior mediastinum with stitches that are taken between the serosa of the stomach and the cut edge of the mediastinal pleura overlying the prevertebral fascia. Anchoring the stomach under tension in a cranial direction not only adds length to the isoperistaltic segment, but prevents its contraction from the cervical suture line as muscular tone returns during the postoperative period. A further maneuver to gain increased length of an isoperistaltic stomach was taught to one of us (H.S.G.) by Professor G. B. Ong, the Professor of Surgery at the University of Hong Kong, who has shown that the isoperistaltic stomach is a muscular tube which when milked and kneaded by hand can stretch several extra inches when added length is necessary. References 1. Akiyama, H., Miyazono, H., Tsurumaru, M., et al.: Use of the Stomach as an Esophageal Substitute. Ann. Surg., 188:606, 1978. 2. Shiu, M. H. and Ong, G. B.: Blood Supply of the Colon in Relation to Oesophageal Replacement. Post-mortem Study of 250 Autopsy Cases. (Paper read by Shiu at the 3rd Malaysian Congress of Medicine, Kuala Lumpur, Malaysia, August, 11-13, 1967). Unpublished data. 3. Gavriliu, D.: Aspects of Esophageal Surgery. Curr. Probl. Surg., 12:36, October, 1975. 4. Heimlich, H. J. and Winfield, J. M.: Use of Gastric Tube to Replace or Bypass Esophagus. Surgery, 17:549, 1955.
A comparative study between Japanese and Americans was carried out to determine gastric characteristics of the two groups, since Japanese appear to allow easier gastric transposition to the neck. Japanese were found to have a longer and more mobile stomach, but in the vast majority of Americans an esophagogastric anastomnosis in the neck is possible following an extensive Kocher maneuver.
IN SPITE OF DISTRESSINGLY poor survival statistics following surgery for esophageal carcinoma, many surgeons continue to believe that there is an important place for surgery in this disease; if not for cure, certainly for palliation. Surgeons in the Far East have reported little difficulty in mobilizing the intact stomach into the neck in order to reestablish gastrointestinal continuity following esophagectomy.1 However, most American surgeons have not exhibited a routine surgical ease in performing this maneuver. This apparent discrepancy in the technical skill required for gastric transposition to the neck has raised the question as to whether there is something different between the stomach of a Japanese as compared to an American. The purpose of this study was to address this possibility by measuring the physical dimensions of the stomach of these two racial groups. Materials and Methods
Seventy patients were included in the study; half from the United States (Philadelphia and Hanover) and the remainder from Japan (Tokyo). There were 20 males and 15 females in the Japanese group and 17 males and 18 females in the United States group. The individuals studied were random autopsy specimens who had died from various medical and surgical conditions which had not involved the esophagus, stomach, or diaphragm. * Professor of Surgery, Dartmouth Medical School. t Chief, Department of Surgery, Toranomon Hospital, Tokyo, Japan. Reprint requests: Harry S. Goldsmith, M.D., Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire 03755. Submitted for publication: May 9, 1979.
From The Departments of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire and Toranomon Hospital, Tokyo, Japan
Six gastric measurements were made in order to assess the physical characteristics of the oriental and occidental stomach. These measurements (in centimeters) included the following: 1) the distance from the sternal notch to the hyoid bone; 2) the distance from the costal angle to the sternal notch; 3) the length of the lesser curvature of the stomach; 4) the length of the greater curvature of the stomach; 5) the distance between the pylorus, as measured at the pyloric vein, and the diaphragm after the duodenum had undergone an extensive Kocher maneuver which required the mobilization of the entire second portion of the duodenum and the head of the pancreas as far medially as the vena cava; 6) the distance between the costal angle and the cardioesophageal junction. A seventh measurement in the study was the height of the patient (Figs. 1 and 2). Results
Japanese men and women, as expected, were found to be shorter than their American counterparts (Figs. 3 and 4). The Japanese group also demonstrated a shorter distance between the costal margin and the sternal notch which simply reflected the shorter longitudinal thoracic length consistent with their overall decrease in total body height. Necks of Japanese and Americans were found to be relatively comparable as measured by the distance from the sternal notch to the hyoid bone. The distance between the costal angle and the cardioesophageal junction showed a slight increase in Japanese men and women as compared to Americans. The significance of this measurement appears of little importance other than to raise the possibility that mobilizing the stomach into the neck in a Japanese patient requires a slightly longer distance if placed in
0003-4932/79/1200/0690 $00.70 © J. B. Lippincott Company
690
Vol. 190 . No. 6
COMPARISON OF GASTRIC DIMENSIONS
691
FIGS. I and 2. Illustrations of the various gastric dimensions measured in the study.
190
ANGLE TO NOTCCH
BODY HEIGHT
LESSER-
GREATER CURVATURE
0 A
185
_
o
180
175
E
0
080
70
J:
O 00
160
z 155
A
00
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0
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40
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A
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165
FIG. 3. Individual gastric measurements of Japanese and American subjects. Stipled line indicates mean measurements. Eighteen Japanese had their pylorus elevated to or above diaphragm compared to seven Americans.
I a
0
I
Ju
a t~~~~a
0
r
I
I
JAPANESE US WHITE
fi2
JAPANESE U.S. WHITE
GOLDSMITH AND AKIYAMA
692 190
65
185. 180
60_
175.
170 165
-
I
160 CD z 155 wi 150 145
.
-
Ann. Surg. * December 1979
esophagogastric anastomosis. This feat would be very difficult, if not impossible, in an American who characteristically is taller than his Japanese counterpart. It must be stressed, however, that in those Americans in this study whose pylorus could not be brought close to the diaphragm, it was still possible in the majority of these individuals to mobilize the stomach into the neck.
-
55 50_ 45_ 40_
35 30_ 25 20a 15 -
Discussion The large bowel which frequently has been used to replace a resected esophagus is always bacterially 01 contaminated regardless of the thoroughness of a 1CI preoperative antibiotic bowel preparation. Additionally, its use as an esophageal replacement requires 0 BODY ANGLE LESSER GREATER multiple anastomoses; a colocolostomy, a cologasHEIGHT TO NOTCH CURVATURE CURVATUREE trostomy and a coloesophagostomy. Another serious ,10 limitation of the large bowel is the awareness that 5% 1r9 of all colons have an inadequate arterial blood supply and 15% a deficient venous out-flow tract when used 12F as an esophageal substitute.2 These serious drawbacks E in a colon bypass following esophagectomy has led to 10F many serious postoperative complications includ8 ing death. CD The major problems associated with a colon bypass z 2 in increasing interest in the use of a reversed resulted IJ gastric tube made from the greater curvature of the 4 stomach as originally described by Gavriliu3 and co popularized by Heimlich.4 This tube is antiperistaltic L1 R1 and requires an extensive suture line to close the deMIDIPOIN NOTCH PYLORIC TO HYOID VEIN fect along the greater curvature of the stomach and to make the gastric tube itself. It is reasoned by the FIG. 4. Range and mean of gastric measurements of subjects authors that if a tube made from a portion of the studied. Note restricted pyloric mobility of Americans compared to Japanese. 0: Japanese males (20). A: Japanese females (15). stomach can be a suitable substitute for an esophagus, 0: U.S. white males (17). A: U.S. white females (18). why wouldn't an isoperistaltic stomach be easier to construct and be superior physiologically when used for a retrosternal or a subcutaneous position relative to this purpose. the same maneuver in an American. Anastomosing the isoperistaltic stomach to the The Japanese were found to have a longer greater cervical esophagus allows complete resection of the curvature of the stomach with the Americans having a thoracic esophagus which is highly desirable because longer lesser curvature. Both these measurements have of the known propensity of an esophageal malignancy significant implications when one is attempting to to spread by intramural extension. Another positive lengthen the stomach for subsequent anastomosis to aspect in using the isoperistaltic stomach as an the cervical esophagus. Of greater importance in gastric esophageal substitute is that its construction allows mobilization is the distance that remains between the for the excision along the proximal half of the lesser pylorus (as measured from the pyloric vein) and the curvature of gastric lymph nodes which frequently diaphragm following an extensive Kocher maneuver. harbor metastatic tumor from the primary esophageal It was found that the Japanese could have their pylorus neoplasm. elevated up to, and even above, the diaphragm with If an anastomotic disruption occurs in the neck follittle difficulty in comparison to Americans in whom lowing gastric transposition, it usually is not the result there is great variability in accomplishing this of vascular compromise, but of technical error because maneuver. One of us (H.A.) has shown that in an of the extensive intramural vascular network supplied occasional Japanese patient, it is not even necessary by the right gastric and the right gastroepiploic arteries and veins. This vast vascular network is not present to do a Kocher maneuver in order to perform a cervical -
-
-
I
1
w
3
6
-
w
Vol. 190 * No. 6
COMPARISON OF GASTRIC DIMENSIONS
in a reversed antiperistaltic gastric tube. Fortunately, any anastomotic leak in the cervical area results in only a cutaneous fistula as opposed to the catastrophe that can occur when there is disruption of an esophageal anastomosis in the chest which invariably leads to empyema and often death. This study which has compared the physical dimensions of American and Japanese stomachs indicates that there are gastric characteristics which allow easier gastric transposition into the neck in Japanese patients. It must be reemphasized, however, that it was possible in approximately 75% of the Americans in this study to bring the stomach into the neck following an extensive Kocher maneuver. In the other 25%, a Kocher maneuver was not sufficient to accomplish this, but there are several maneuvers which are possible if one were performing surgery on these individuals which would allow the construction of a gastroesophageal anastomosis in the neck. This first maneuver is to place the stomach in the chest along the route which follows the shortest distance to the neck. The shortest distance between the peritoneal cavity and the cervical region is by way of the posterior mediastinum with the retrosternal and subcutaneous positions, respectively, being longer in length. A second maneuver which helps one compensate in those patients whose stomachs appear too short for a
693
cervical anastomosis is to suture the gastric segment under tension along the posterior mediastinum with stitches that are taken between the serosa of the stomach and the cut edge of the mediastinal pleura overlying the prevertebral fascia. Anchoring the stomach under tension in a cranial direction not only adds length to the isoperistaltic segment, but prevents its contraction from the cervical suture line as muscular tone returns during the postoperative period. A further maneuver to gain increased length of an isoperistaltic stomach was taught to one of us (H.S.G.) by Professor G. B. Ong, the Professor of Surgery at the University of Hong Kong, who has shown that the isoperistaltic stomach is a muscular tube which when milked and kneaded by hand can stretch several extra inches when added length is necessary. References 1. Akiyama, H., Miyazono, H., Tsurumaru, M., et al.: Use of the Stomach as an Esophageal Substitute. Ann. Surg., 188:606, 1978. 2. Shiu, M. H. and Ong, G. B.: Blood Supply of the Colon in Relation to Oesophageal Replacement. Post-mortem Study of 250 Autopsy Cases. (Paper read by Shiu at the 3rd Malaysian Congress of Medicine, Kuala Lumpur, Malaysia, August, 11-13, 1967). Unpublished data. 3. Gavriliu, D.: Aspects of Esophageal Surgery. Curr. Probl. Surg., 12:36, October, 1975. 4. Heimlich, H. J. and Winfield, J. M.: Use of Gastric Tube to Replace or Bypass Esophagus. Surgery, 17:549, 1955.
