Merendino interposition - 6 month update

For those who have not seen my previous posts on this farely rare op, its for T1 cancer of the oesophagus and stomach where a length of jejunum (intestine), 10cm in my case is placed between the remaining oesophagus and remaining stomach, if any. The main advantage of this op is no reflux in 90% of cases. The history of this op goes back 50 years or more when the op was done originally for those suffering from bad acid reflux. It has more recently been introduced for T1 cancer sufferers.

6 months after my op I have just had a followup meeting with my surgeon. I am fit and just about back to normal except for the usual digestive problems of in my case occasional dumping with associated feeling very ill occasions due to insulin dumping (is this what causes all dumping?). I have no reflux and hence can carry on with my car maintenance under the car! I do suffer cramping after meals and lots of wind with a blown out feeling. I can induce relief by force burping. I burp normally, a lot. I asked the surgeon where I burp from and he said he did not know! As one would expect everybody is different.

I asked why I was not getting reflux. It was expalined to me that jejunum is a very soft curly tube that opens up as food passes down and forms like a spiral. Food reflux is then very difficult. I have noticed initial reluctance of food to pass down the jejunum until it has opened up presumably due to gravity! A few minutes later food passes down easily if the remaining stomach is not full of wind. A survey performed many years ago and available on the internet shows about 90% non reflux success.

I learnt from a lot of research that the jejunum is actually better at resisting acid attack than the oesophagus and stomach. When you think about it food and acid go down into the intestines.

Like always these are my personal observations and patients should discuss this option for T1 with their surgeon. The same result does not always result. This operation is sometimes offered where there is only T1 cancer which the surgeon is sure has not spread. Lifestyle is much better than the 'traditional pull up' with the ensuing reflux problem.

It would be interesting to ask surgeons where the pull up is being performed, if jejunum can be inserted further down with twisty bits to stop reflux? Can anybody answer this?

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  • Definitely a surgeon's question I think!

    My reaction is that your stomach is probably in more or less its normal place, compared to other versions of the operation, and that it has not been re-positioned higher into your chest. Therefore the space between your stomach and your mouth is not so short, and the reflux might therefore feel less, notwithstanding that the valve between stomach and the 'new' oesophagus would presumably no longer be there. The lining of the stomach is indeed better at resisting acid than the oesophagus, so the same may well apply to jejunum. It is worth thinking that reflux may not always be acid, it might be bile, which is an alkali, and tastes even worse, in my experience.

    We had a session with Professor Robert Mason of St Thomas's on Saturday, and, amongst other things, he said (to the best of my memory) that different parts of the digestive system used to replace the oesophagus could vary in their ability to replicate the motility (speed of processing food) of the oesophagus. In other words some sections were better at maintaining, especially long term, the regular spasms needed to take the food down the digestive system. This is an unusual version of the operation and something not to be contemplated without the support of your surgeon. Over the years the failure rate was shown to be a little bit higher (which does not mean of course that your progress has not been good or will continue to be so).

    I am sure that the stomach not being in the chest must help with reducing the problems doing heavy-ish work in awkward positions.

    So, again, definitely an issue for the surgeon's advice!

    The late dumping (2 hours or more after eating) is caused by the cutting of the vagus nerve, the nerve that controls the motility, the shortened digestive system, and various nerves in spots in the system that act as 'pacemakers' that get triggered as food passes through. The rapid processing of food triggers excess insulin production because the body thinks it is having to absorb far more sugar than normal. Moisture gets sucked in from the bloodstream and you therefore may feel dizzy and light-headed, and it might contribute to the cramps. So the system gets unbalanced. Taking something like a dextrosol tablet will have a rapid effect on re-balancing the sugar:insulin ratio, and will demonstrate whether the body sugar ratio was right or not. Do also think carefully about low glycemic index food and see whether that makes a difference.

    Flatulence might be to do with the body absorbing more air than normal. Things like Actimel do not do any harm, and might help (despite reluctance to believe adverts). It would be worth keeping a careful review of your diet, and it is probably trial and error to work out what might affect it more than others (a wind diary?). There may be something in the content of your gut that contributes, so sometimes having a test for whether your mineral / vitamin levels are normal might be worthwhile.

    It is really good to hear about your progress, especially after all the considerations that went on before your surgery.

    Kind regards

    Alan

  • Thanks for your comments Alan which I'm sure are correct. The item I picked up on was "over the years the failure rate was shown to be a little higher". Now with no data on what can fail, I cannot comment but I did investigate on the internet and with my surgeon the longevity ot this operation and it was a deciding factor in my decision to go this way rather then the pull up. The op goes way back 50 years for an acid reflux solution which has been more recently used for T1 cancer. All the reports I have seen suggest longevity and my surgeon last week confirmed this.

    I would be interested to know what failures can occur which are probably similar to pull up. Are they structural failures or the return of cancer? I would have thought that it is the later and dependent upon if all the cancer cells have been removed. Pull up removes more tissue and I suppose having less removed is riskier as some cancer cells may remain. My surgeon is confident that all the cancer cells have been removed as no cancer cells were present around the edges of the cancerous portion removed. There can of course be another separate cancer. My surgeon has stated that the cancer removed will not return.

    I hope the comments I am making are useful in helping others to make a structured decision as there is not an enormous amount of data available to the public on the Merendino op for cancer. I do agree and stress that patients need to discuss this with their medical team before making a decision. My decision was based upon retaining a good lifestyle and upon a diagnosis that the cancer was early stage or it would not have been offered to me.

  • The issue, as I understood it, and I may be wrong, is that over time the replacement oesophagus tends to get a bit 'flabby' and a bit 'lazier' in relation to the spasms that take the food down the system. I do not think it was anything to do with removal of the margins around the tumour, so it was not to do wioth the cancer side of things.

  • My surgeon explained the 'jejunum' replacement for part of the oesophagus as a very soft spirally tube that is mainly closed until food enters it and it opens up to transit the food by squeezing it down. This is why there is no reflux. Partially closed and a difficult path for any reflux. Wonder why full pullup is not the same. Maybe its to do with which part of the intestines is used. Perhaps jejunum from lower down in the 'dirty' part is different from higher up which is connected to the rest of the remaining oesophagus in full pull up..

    He also commented that without the sphincter muscle in the diaphram 'things move around' a little and may not be in the same place as before. I assume this applies to a full pullup or the insertion of a length of jejunum. I think my remaining stomach may be further to my left than usual as I feel very full after eating just below my left side ribs and it does feel to me that food and wind exits to my left side which is not the original route! I can hear gurgles and feel the relief there.

  • My wife has just reminded me what my surgeon said before the merendino op. If the colon is used as the interposition between oesophagus and remaining stomach it gets flabby with time. Mine was taken from 'further up' whatever that means but was described as 'dirty' and I was immediately put on antibiotics after the op and the scar bled of infection as a standard treatment, not because i picked up an infection during the op.

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