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??Comparison of quality of life between proximal versus total gastrectomy for adenocarcinoma of gastroesophageal junction DAI Bin*, PAN Lin, YANG Chen, et al. *Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
Corresponding author: HU Jian-kun, E-mail: hujkwch@126.com
Abstract Objective To compare quality of life (QLQ) after proximal gastrectomy (PG) or total gastrectomy (TG) for adenocarcinoma of gastroesophageal junction (AEG) (Siewert type II/III). Methods Siewert type II/III AEG cases performed either PG with esophagogastric anastomosis or TG with Roux-en-Y esophagojejunal reconstruction between January 2006 and December 2009 at West China Hospital of Sichuan University were analyzed retrospectively. Patients were followed up by telephone at six months or more after the surgery and QLQ was assessed by EORTC QLQ-C30 and QLQ-STO22 questionnaires. Results A total of 98 cases were Siewert type II/III AEG with 30 dead and 8 lost to follow up. Data from 40 cases in PG group and 20 in TG group were analyzed. There were no significant differences of baselines between two groups related to sex, age, tumor size, TNM stage (AJCC, 6th version) or hospital stay after surgery. TG group scored better than PG group in global health status without significant difference (P=0.072). PG group reported worse scores than TG group with respect to reflux symptoms, dysphagia, eating restrictions, nausea and vomiting, appetite loss, taste abnormality, social functioning and insomnia (P<0.05). Moreover, TG group scored worse than PG group regarding to dyspnoea (P=0.027). Conclusion Siewert type II/III AEG patients treated by TG have a better QLQ than that of PG, especially on the aspects of reflux controlling and appetite improvement.     

Chronic abdominal pain and quality of life after Roux-en-Y gastric bypass and sleeve gastrectomy – a cross-cohort analysis of two prospective longitudinal observational studies

BackgroundChronic abdominal pain (CAP) after bariatric surgery is not extensively explored and may impact the postoperative outcomes.ObjectiveTo compare the prevalence of patient-reported chronic abdominal pain (CAP) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Secondarily, we compared other abdominal and psychological symptoms and quality of life (QoL). Preoperative predictors of postoperative CAP were also explored.SettingTertiary referral centers for bariatric surgery in Norway.MethodsAnalyses of 2 separate prospective longitudinal cohort studies evaluating CAP, abdominal and psychological symptoms and QoL before and 2 years after RYGB and SG.ResultsFollow-ups were attended by 416 patients (85.8%), 300/416 (72.1%) were females and 209/416 (50.2%) were RYGB procedures. At follow-up, the mean age was 44.9 (10.0) years, BMI 29.5 (5.4) kg/m², and total weight loss 31.6 (10.3) %. The prevalence of CAP was 28/236 (11.9%) before and 60/209 (28.7%) after RYGB (P < .001) and 32/223 (14.3%) before and 50/186 (26.9%) after SG (P < .001). Gastrointestinal symptom rating scale scores showed greater deterioration of diarrhea and indigestion after RYGB and reflux after SG. The improvement in depression symptoms was greater after SG, as well as several QoL scores improved more after SG. Patients with CAP after RYGB experienced deterioration in several QoL scores, while these scores improved in patients with CAP after SG. Preoperative hypertension, bothersome reflux symptoms, and CAP predicted postoperative CAP.ConclusionsThe prevalence of CAP increased comparably after RYGB and SG, with worsening of gastroesophageal reflux after SG and greater deterioration of diarrhea and indigestion after RYGB. In patients with CAP at follow-up, several QoL scores improved more after SG than RYGB.     

Repair of post–bariatric surgery,recurrent, and de novo hiatal hernias improves bloating,abdominal pain,regurgitation, and food intolerance

BackgroundPost–bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF).ObjectivesTo report the short-term outcomes of repairing post–bariatric surgery hiatal hernias in patients with BARF.SettingLarge, multispecialty group practice with university affiliation.MethodsWe reviewed the records of all consecutive patients who underwent repair of post–bariatric surgery hiatal hernias (2012–2020). Data are shown as means ± standard deviations.ResultsWe repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients.ConclusionsHiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post–bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients.     

Subtotal Gastrectomy with Limited Lymph Node Dissection is a Feasible Treatment Option for Patients with Early Gastric Stump Cancer

The de facto standard treatment for early gastric stump cancer (GSC) has been total gastrectomy combined with radical lymph node dissection. However, some patients could benefit if partial resection of the gastric stump is feasible. We investigated the feasibility of subtotal gastrectomy for early GSC as less invasive surgery. Subtotal gastrectomy was defined as a segmental resection of the gastric remnant including the anastomosis with limited lymph node dissection. A total of 66 patients with early GSC were enrolled and 24 patients (36.4 %) underwent subtotal gastrectomy (SG group). Clinicopathological characteristics were analyzed along with those of the other 42 patients (63.6 %) who underwent total gastrectomy (TG group). There were no significant differences between the two groups in the number of lymph nodes harvested (p?=?0.880). Lymph node involvement was detected in 2 patients (8.3 %) in SG group and 5 patients (11.9 %) in TG group (p?=?1.000). The previous disease (benign or malignant) and surgery (Billroth I or II) did not affect the rate of nodal involvement. The 5-year overall survival rate of SG group (94.7 %) was acceptable. Subtotal gastrectomy of the gastric remnant could be a feasible treatment option for patients with early gastric stump cancer when indicated.     

The use of nonsteroidal anti-inflammatory drugs after sleeve gastrectomy

BackgroundThe use of nonsteroidal anti-inflammatory drugs (NSAIDs) is discouraged after bariatric surgery. The effect of NSAIDs on patients who have undergone sleeve gastrectomy (SG) is not well studied. Moreover, the rate of NSAID use after SG is unknown.ObjectivesTo determine the rate of NSAID use after SG, and its associated complications.SettingA single institution, multi-surgeon, academic, tertiary care hospital.MethodsWe performed a retrospective review of patients who underwent SG between January 1, 2014, and November 1, 2017. A phone interview was conducted with identified patients. The inclusion criteria were any patient who had undergone SG during the study period, and there were no exclusion criteria.ResultsWe identified 421 SG patients for inclusion. There were 231 phone surveys completed, with 64.5% of respondents reporting some NSAID use after SG. Of the respondents who used NSAIDs, 40.3% reported that they used the drugs often (>once/wk), 28.2% reported occasional use (>once/mo but <once/wk), and 31.5% reported rare use (<once/mo). Nearly 26% of phone interview respondents regularly used NSAIDs after SG. A retrospective review of the 421-patient cohort revealed 0 cases of sleeve complications secondary to NSAID use when searching for incidences of bleeding, ulceration, gastritis, gastropathy, perforation, leak, or stenosis.ConclusionNSAID use in our bariatric surgery population is high despite an institutional policy to prohibit their use across all bariatric patients. Despite the high incidence of NSAID use in our patient population, we could not identify a single case of an NSAID-induced gastrointestinal complication in our retrospective review. NSAID use after SG may be a safe and viable pain management strategy that needs further evaluation.     

Distal Gastric Cancer and Extensive Surgery: A New Evaluation Method Based on the Study of the Status of Residual Lymph Nodes After Limited Surgery

Background: Curative resection (R0) is the treatment of choice for distal gastric cancer, but it is unclear whether this operation should include a total gastrectomy (TG) with splenectomy and extended (D2) lymph node dissection. A new concept was developed based on the fact that residual metastatic lymph nodes after a limited (D1) subtotal gastrectomy (SG) may be the source of fatal relapse. We conducted a prospective study on patients who had undergone a D2 TG to evaluate whether certain stations left behind after a D1 SG contain metastasis.Methods: We studied 1207 nodes obtained from 35 eligible patients who underwent a TG within 2 years. Of these patients, 29 fulfilled the criterion for a D2 dissection with curative potential. Numbers of retrieved and tumor-containing nodes by each station according to the Japanese Research Society for Gastric Cancer were documented prospectively in a standardized protocol. All lymph nodes were studied in sections smaller than 2 mm, but emphasis was given to the study of nodes from stations 1 and 2 (paracardial right and left), station 10 (splenic hilum), and stations 7 through 12 (around celiac axis, and in hepatoduodenal ligament) that can be dissected with a TG, splenectomy, and D2 dissection, respectively. For quality control of D2 dissection, the numbers ofnodes retrieved by each compartment II nodal station (7–12) documented by a pathologist were used and compared with proposed reference values. Long-term survival and cumulative risk of relapse were calculated in terms of lymph node status and presence of metastasis in compartment II nodes.Results: A mean total node yield of 37.4 from stations 1–12 and 11.4 from compartment II (stations 7–12) was obtained from 29 patients who had a D2 TG with curative intent. A substantial variation in node yields was found, and sometimes several stations contained no lymph nodes, which suggested an important cause of noncompliance (no yield of lymph nodes detected by the pathologist from that indicated for dissection stations) and difficulties for quality control. No positive node was detected in stations 1, 2, and 10 among patients who had a curative TG with splenectomy. However, substantially high was the incidence of metastasis in compartment II nodes, which was detected in one third of patients with node-positive disease. After 10 years of follow-up, overall survival and relapse rates among R0 D2 patients with negative compartment II nodes (pN0/pN1 disease) were 47% and 44%, respectively.Conclusions: Our results suggest the necessity of D2 dissection, but not of TG with splenectomy, to achieve an R0 resection for patients with distal gastric carcinoma. A large prospective study based on our protocol and findings may clarify whether a D2 R0 resection would result in a survival benefit.     

Quality of life after sleeve gastrectomy and adjustable gastric banding

BackgroundWith the addition of laparoscopic vertical sleeve gastrectomy (SG) to the bariatric surgery procedural toolkit, patients desiring a restrictive bariatric procedure often choose between adjustable gastric banding (LAGB) and SG. One study compared quality of life after these 2 procedures and found no difference. The purpose of our study was to re-evaluate the postoperative quality of life in LAGB and SG patients at a military teaching hospital in the United States.MethodsA retrospective review of 108 consecutive laparoscopic restrictive bariatric procedures performed within 15 months at a Department of Defense hospital was conducted. Of these 108 patients, 69 had undergone laparoscopic vertical SG and 39 LAGB. A validated quality of life questionnaire (Bariatric Quality of Life) was conducted a mean of 9.3 ± 3.2 months (range 5–16) postoperatively. The weight loss and standard laboratory parameters were measured at 0, 1, 3, 6, and 12 months.ResultsThe quality of life assessment revealed significantly better scores after SG than after LAGB (66.5 versus 57.9, P = .0002). The excess weight loss and excess body mass index loss at 3, 6, and 12 months postoperatively were significantly greater in the laparoscopic SG group. The patients demonstrated a clear preference over time for SG once it was offered.ConclusionEarly postoperative quality of life was superior after SG than after LAGB. SG also resulted in superior early excess weight loss. In a practice not constrained by reimbursement, these findings were associated with increased patient choice of SG after it began to be offered.     

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study.

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.     

Quality of life after esophageal replacement in children

PurposeAssessing quality of life (QoL) after esophageal replacement (ER) for long gap esophageal atresia (LGEA).MethodsAll patients after ER for LGEA with gastric pull-up (GPU n = 9) or jejunum interposition (JI n = 14) at the University Medical Center Groningen and Utrecht (1985–2007) were included. QoL was assessed with 1) gastrointestinal-related QoL using the Gastrointestinal Quality of Life Index (GIQLI)), 2) general QoL (Child Health questionnaire CHF87-BREF (children)/World Health Organization questionnaire WHOQOL-BREF (adults)), and 3) health-related QoL (HRQoL) (TNO AZL TACQoL/TAAQoL). Association of morbidity (heartburn, dysphagia, dyspnea on exertion, recurrent cough) and (HR)QoL was evaluated.ResultsSix patients after GPU (75%) and eight patients after JI (57%) responded to the questionnaires (mean age 15.7, SD 5.9, 12 male, two female). Mean gastrointestinal, general and health-related QoL total scores of the patients were comparable to healthy controls. However, young adults reported a worse physical functioning (p = 0.02) but better social functioning compared to peers (p = 0.01). Morbidity was not associated with significant differences in (HR)QoL.ConclusionsWith the current validated QoL most patients after ER with GPU and JI for LGEA have normal generic and disease specific QoL scores. Postoperative morbidity does not seem to influence (HR)QoL.Type of StudyPrognosis Study.Level of evidenceIII.     

Total gastrectomy versus partial gastrectomy of adenocarcinoma of the antrum. A French prospective controlled study

In a prospective multicentric trial we compared the post-operative mortality and the 5-year survival of elective total gastrectomy (TG) versus subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study: thirty two were excluded after pathological examination (linitis plastica, superficial cancer, lymphoma). One hundred and sixty nine patients remained for analysis with 93 TG and 76 SG. Elective TG did not increase post-operative mortality (1.3%) in comparison with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both operations TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.     

Ecological momentary assessment of gastrointestinal symptoms and risky eating behaviors in Roux-en-Y gastric bypass and sleeve gastrectomy patients

BackgroundGastrointestinal symptoms (GIS) are common after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). However, little is known about frequencies of GIS and their co-occurrence with risky eating behaviors.ObjectivesCompare RYGB and SG on GIS and risky eating behaviors, and test associations between GIS and behaviors.SettingTwo university hospitals in Northeastern United States.MethodsRYGB (n = 18) and SG (n = 53) patients completed smartphone-based ecological momentary assessment of GIS and risky eating behaviors at 4 semi-random times daily for 10 days preoperatively and at 3, 6, and 12 months postoperatively. Study objectives were evaluated using generalized linear mixed-effects models.ResultsAll available data from each assessment were included in the analysis: participant attrition was 18%, 30%, and 38% at 3, 6, and 12 months. All GIS were reduced at 12 months postoperative. Bloating decreased consistently whereas cramping, dehydration, and dumping first increased at 3 to 6 months then decreased to 12 months. Diarrhea, nausea, reflux, and vomiting decreased to 12 months for RYGB, but first increased at 3 to 6 months then decreased to 12 months for SG. Consumption of carbonated and sugar-sweetened beverages, fatty meats, and sweets decreased to 6 months then rebounded at 12 months. Eating past the first sign of fullness, drinking liquids with meals, not starting meals with protein, and fried foods consumption decreased to 6 months and then rebounded for RYGB only at 12 months. Alcohol consumption did not change. Sweets consumption and eating past the first sign of fullness were most consistently associated with GIS for both RYGB and SG patients.ConclusionGIS and risky eating behaviors improved postoperatively, although patterns of change were variable and occasionally differed between RYGB and SG. Pending replication, patients may benefit from intervention to limit risky behaviors that are tailored to their surgery type.     

Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

BackgroundHiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.ObjectiveThis study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.SettingUniversity hospital, United States.MethodsAs part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.ResultsBetween November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection.ConclusionHiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.     

Diagnoses related to abuse of alcohol and addictive substances after gastric bypass and sleeve gastrectomy: a nation-wide registry study from Norway

BackgroundAfter Roux-en-Y gastric bypass (RYGB) patients are at higher risk of alcohol problems. In recent years, sleeve gastrectomy (SG) has become a common procedure, but the incidence rates (IRs) of alcohol abuse after SG are unexplored.ObjectivesTo compare IRs of diagnoses indicating problems with alcohol or other substances between patients having undergone SG or RYGB with a minimum of 6-month follow-up.SettingAll government funded hospitals in Norway providing bariatric surgery.MethodsA retrospective population-based cohort study based on data from the Norwegian Patient Registry. The outcomes were ICD-10 of Diseases and Related Health Problems diagnoses relating to alcohol (F10) and other substances (F11–F19).ResultsThe registry provided data on 10,208 patients who underwent either RYGB or SG during the years 2008 to 2014 with a total postoperative observation time of 33,352 person-years. This corresponds to 8196 patients with RYGB (27,846 person-yr, average 3.4 yr) and 2012 patients with SG (5506 person-yr; average 2.7 yr). The IR for the diagnoses related to alcohol problems after RYGB was 6.36 (95% confidence interval: 5.45–7.36) per 1000 person-years and 4.54 (2.94–6.70) after SG. When controlling for age and sex, adjusted hazard ratio was .75 (.49–1.14) for SG compared with RYGB. When combining both bariatric procedures, women <26 years were more likely to have alcohol-related diagnoses (3.2%, 2.1–4.4) than women of 26 to 40 years (1.6%, 1.1–2.1) or women >40 (1.3%, .9–1.7). The IR after RYGB for the diagnoses related to problems with substances other than alcohol was 3.48 (95% confidence interval: 2.82–4.25) compared with 3.27 (1.94–5.17) per 1000 person-years after SG. Controlling for age and sex, the hazard ratio was .99 (.60–1.64) for SG compared with RYGB.ConclusionsIn our study, procedure-specific differences were not found in the risks (RYGB versus SG) for postoperative diagnoses related to problems with alcohol and other substances within the available observation time. A longer observation period seems required to explore these findings further.     

Gastric leak after sleeve gastrectomy: risk factors for poor evolution under conservative management

BackgroundGastric leak (GL) is the most highly feared early postoperative complication after sleeve gastrectomy (SG), with an incidence of 1% to 2%. This complication may require further surgery/endoscopy, with a risk of management failure that may require additional surgery, including total gastrectomy, leading to a risk of mortality of 0% to 9%.ObjectivesAssess the impact of factors that may lead to a poorer evolution of GL.SettingUniversity Hospital, France, public practice.MethodsThis was a retrospective, single-center study of a group of patients managed for GL after SG between November 2004 and January 2019 (n = 166). Forty-three patients were excluded. The population study was divided into 2 groups: patients with easy closing of the GL (n = 73) and patients with difficult closing of the GL or failure to heal (n = 50). Patients were allocated to 1 of 2 groups depending on the time to heal (median time of 84 days). The study's primary efficacy endpoint was to determine the risk factors for a poorer evolution of GL.ResultsAmong 123 patients included in this study, 103 patients had undergone primary SG (83.7%). The mean time to the appearance of GL was 15.1 days (range, 1–156 d). Seventy-four patients underwent a reoperation (60%). The mean number of endoscopies per patient was 2.7 (range, 2–7 endoscopies). The mean time to healing was 89.5 days (range, 18–386 d). There were 8 cases of healing failure (6.5%). Multivariate analysis identified body mass index (>47 kg/m²), time to referral (>2 d), and serum prealbumin level (<.1 g/dL) to be independent risk factors for a poorer evolution of GL.ConclusionImprovement of nutritional status before SG and early referral for GL could reduce the risk of delayed closure or the need for further surgery.     

Predictive value of preoperative DeMeester score on conversion to Roux-en-Y gastric bypass for gastroeosophageal reflux disease after sleeve gastrectomy

BackgroundObesity is well known to increase the risk of gastroesophageal reflux disease (GERD). The impact of sleeve gastrectomy (SG) on GERD is still discussed but seems to be associated with the development of de novo GERD or the exacerbation of preexisting GERD.ObjectiveThe objective of this study was to evaluate the impact of preoperative pH monitoring, using the DeMeester score (DMS), on the risk of conversion to Roux-en-Y gastric bypass (RYGB) after SG.SettingUniversity Hospital in Nantes, France.MethodsThis monocentric study reported the results of a retrospective chart review of 523 obese individuals treated between 2011 and 2018. All patients underwent primary bariatric surgery; 95% had undergone an SG. GERD diagnosis was established with preoperative DMS based on 24-hour esophageal pH monitoring.ResultsPreoperative DMS was identified in 423 patients (86%). Sixty-seven patients (14%) underwent a second bariatric procedure; among them, 36 (54%) have been converted to RYGB because of GERD. There was no significant difference between preoperative DMS (16.1 ± 22 versus 13.7 ± 14, P = .37) in patients undergoing conversion for GERD and the nonconverted ones. The sensitivity, specificity, positive predictive, and negative predictive values of the preoperative DMS for predicting conversion to RYGB were 25%, 66%, 7%, and 4%, respectively. In patients who underwent a conversion for GERD, DMS (P < .002), rates of esophagitis (P = .035), and hiatal hernia (P = .039) significantly increased after SG.ConclusionPreoperative DMS alone is not predictive of the risk of conversion of SG to RYGB for GERD.     

Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem

Many surgeons favour total gastrectomy (TG) 'de principe' in the treatment of gastric cancer, but final demonstration of its advantage over subtotal gastrectomy (SG) is still lacking. We analysed survival after curative TG or SG within groups of patients stratified according to the main prognostic variables as found in multivariate analysis, i.e., nodal status, degree of invasion of the gastric wall, patient age and sex. Our series consisted of 361 patients treated by curative SG and 41 by curative TG, admitted to the Istituto Nazionale Tumori of Milan between 1965 and 1979. In patients with lymph node involvement survival appeared to be significantly better (P = 0.0005) after SG. However, stratifying for age it was found that the benefit was limited to patients over 60 years old. No significant difference in survival was found in the group without nodal involvement (N -) and invasion of the wall to the serosa or beyond. No statistical comparison was possible in N - groups with invasion confined to mucosa, submucosa or muscularis propria because of the small number of such patients who underwent TG. We conclude that SG still represents the standard reference operation for gastric carcinoma provided that a safe proximal margin of resection is guaranteed.     

Critical analysis of feeding jejunostomy following resection of upper gastrointestinal malignancies

AIM To assess nutritional recovery,particularly regarding feeding jejunostomy tube(FJT)utilization,following upper gastrointestinal resection for malignancy. METHODS A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy(subtotal or total)for cancer with curative intent,from January 2001 to June 2014. Patient demographics,the approach to esophagectomy,the extent of gastrectomy,FJT placement and utilization at discharge,administration of parenteral nutrition(PN),and complications were evaluated. All patients were followed for at least ninety days or until death.RESULTS The 287 patients underwent upper GI resection,comprised of 182 esophagectomy(n=107 transhiatal,58.7%; n=56 Ivor-Lewis,30.7%)and 105 gastrectomy [n=63 subtotal(SG),60.0%; n=42 total(TG),40.0%]. 181 of 182 esophagectomy patients underwent FJT,compared with 47 of 105 gastrectomy patients(99.5% vs 44.8%,P 0.0001),of whom most had undergone TG(n=39,92.9% vs n=8 SG,12.9%,P 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups(14.7 d vs 17.1 d,P=0.076). Upon discharge,87 esophagectomy patients(48.1%)were taking enteral feeds,with 53(29.3%)fully and 34(18.8%)partially dependent. Meanwhile,20 of 39 TG patients(51.3%)were either fully(n=3,7.7%)or partially(n=17,43.6%)dependent on tube feeds,compared with 5 of 8 SG patients(10.6%),all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients(6.4% vs 29.3%,P=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy(n=11,23.4% vs n=7,3.9%,P=0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group(n=6),all after TG,compared to 1 esophagectomy patient(12.8% vs 0.6%,P=0.0003). Six of 7 patients(85.7%)who experienced tube-related complications required PN.CONCLUSION Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.     

Quality of life outcomes in patients undergoing surgery for locally recurrent rectal cancer

BackgroundSurvival has been considered the key outcome measure for cancer patients, however quality of life (QoL) is increasingly being considered as an important outcome measure.MethodThe Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL were searched using medical subject headings. Reference lists of identified studies, clinicaltrials.gov and the WHO International Clinical Trials Registry were also searched. All clinical trials which included recurrent rectal cancer and QoL were identified, with restrictions to human, since 2000 and English language.Results16 publications were identified. The studies were quite heterogeneous with regard to the patients included, tools used to assess QoL, times when QoL is assessed and comparator groups; they were further limited by small sample size. Many studies reported combined data with local advanced rectal cancer.ConclusionPatients with recurrent rectal cancer have impaired QoL. Surgery further impairs their QoL, for between 6 and 9 months. The dimensions affected include urinary, and sexual function, feceal incontinence, pelvic pain, muscular skeletal function, and employment. Predictors of poor post operative QoL are poor preoperative Qol, female, and need for a boney resection. Patients who receive an R0 resection have better QoL than those after a R1 or R2 resection.     

Computed tomography assessment of postoperative gastric vascular supply and staple-line leak development after sleeve gastrectomy

BackgroundResidual arterial supply of the gastric tube after sleeve gastrectomy (SG) can be damaged by surgery, which can reduce gastric tube perfusion and could promote postoperative leakage.ObjectiveTo compare the postoperative vascularization of the gastric tube using early computed tomography (CT) scanning after SG in patients with or without postoperative staple-line leak.SettingUniversity hospital.MethodsA retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Patients who presented with a staple-line leak were matched (1:3) with a control group of patients who underwent surgery without postoperative morbidity during the same period. Gastric tube vascularization was studied on a postoperative day 2 CT scan in both groups of patients.ResultsDuring the study period, 1826 patients underwent SG, including 42 patients (2.3%) who presented with a staple-line leak. Those 42 patients were successfully matched to 126 control patients. Global identification of residual gastric arterial supply in early postoperative CT scans was similar in patients with or without staple-line leak after SG. However, residual vascular supply of the gastroesophageal junction (i.e., terminal and anterior cardiotuberosity branches of the left gastric artery or left inferior phrenic artery) was more frequently interrupted by the staple line in the group of patients who developed a gastric leak.ConclusionThis study suggests a correlation between interruption of the main arteries supplying the gastroesophageal junction by the staple line on early postoperative CT scans and the development of gastric leak after SG. These results support the vascular theory as one of the causes of leak after SG.     

Improvement in quality of life after bariatric surgery: sleeve versus bypass

Background

Obesity is steadily growing to be the largest threat to human health in this century, not only increasing prevalence of obesity-related co-morbidity but also impairing health-related quality of life (QoL). Bariatric surgery has shown to improve co-morbidity as well as QoL.