A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: results from a multi-institutional RCT

Background

Both Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed as standard procedures, but it has yet to be determined which reconstruction is better for patients. A randomized prospective phase II trial with body weight loss at 1?year after surgery as a primary endpoint was performed to address this issue. The current report delivers data on the quality of life and degree of postoperative dysfunction, which were the secondary endpoints of this study.

Methods

Gastric cancer patients who underwent distal gastrectomy were intraoperatively randomized to B-I or R-Y. Postsurgical QOL was evaluated using the EORTC QLQ-C30 and DAUGS 20.

Results

Between August 2005 and December 2008, 332 patients were enrolled in a randomized trial comparing B-I versus R-Y. A mail survey questionnaire sent to 327 patients was completed by 268 (86.2%) of them. EORTC QLQ-C30 scores were as follows: global health status was similar in each group (B-I 73.5?±?18.8, R-Y 73.2?±?20.2, p?=?0.87). Scores of five functional scales were also similar. Only the dyspnea symptom scale showed superior results for R-Y than for B-I (B-I 13.6?±?17.9, R-Y 8.6?±?16.3, p?=?0.02). With respect to DAUGS 20, the total score did not differ significantly between the R-Y and B-I groups (24.8 vs. 23.6, p?=?0.41). Only reflux symptoms were significantly worse for B-I than for R-Y (0.7?±?0.6 vs. 0.5?±?0.6, p?=?0.01).

Conclusions

The B-I and R-Y techniques were generally equivalent in terms of postoperative QOL and dysfunction. Both procedures seem acceptable as standard reconstructions after distal gastrectomy with regard to postoperative QOL and dysfunction.     

R-Y吻合在远端胃癌根治术中的应用

目的:探讨R-Y吻合在远端胃癌根治术中的优势。方法:回顾性分析并总结我院近3年56例远端胃癌根治术患者临床资料，B-Ⅱ吻合术组26例，R-Y吻合术组30例。比较两组患者术后并发症及营养状态。结果:R-Y组手术时间略长于B-Ⅱ组（P＜0.05）；R-Y组反流性食管炎发生率低于B-Ⅱ组（P＜0.05），其余并发症差异无统计学意义(P＞0.05)；两组住院天数相似无差异（P＞0.05）；两组患者术后1年BMI变化、白蛋白变化、淋巴细胞计数变化差异无统计学意义(P＞0.05)。结论:R-Y术式在远端胃癌根治术消化道重建中是安全可靠的，反流性食管炎发生率降低，改善了患者术后生活质量，应作为远端胃癌根治术的首选吻合方式。     

Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy

Background

Laparoscopic distal gastrectomy (LDG) is an established procedure for the treatment of early gastric cancer. Roux-en-Y (R-Y) or Billroth-I (B-I) reconstruction is generally performed after LDG in Japan. The aim of this retrospective cohort study was to compare the effectiveness of R-Y and B-I reconstructions and thereby determine which has better clinical outcomes.

Methods

We analyzed data from 172 patients with gastric cancer who underwent LDG. Reconstruction was done by R-Y in 83 patients and B-I in 89. All patients were followed up for 5 years. Evaluated variables included symptoms, nutritional status, endoscopic findings, gallstone formation, and later gastrointestinal complications.

Results

Scores for the amount of residue in the gastric stump, remnant gastritis, and bile reflux, calculated according to the “residue, gastritis, bile” scoring system, were significantly lower in the R-Y group (score 0 vs. 1 and more; p = 0.027, <0.001, and <0.001, respectively). The proportion of patients with reflux esophagitis was significantly lower in the R-Y group (p < 0.001). Relative values (postoperative 5 years/preoperative) for body weight, serum albumin level, and total cholesterol level were similar in the two groups (p = 0.59, 0.56, and 0.34, respectively). Gallstone formation did not differ between the groups (p = 0.57). As for later complications, the incidence of gastrointestinal ulcer was 4.5 % in the B-I group, and that of ileus was 3.6 % in the R-Y group, but differences between the groups were not significant (p = 0.12, 0.11, respectively).

Conclusions

As compared with B-I, R-Y was associated with lower long-term incidences of both bile reflux into the gastric remnant and reflux esophagitis.     

Use of a segment of transverse colon as a gastric substitute after total gastrectomy: an audit of 18 patients

Background. Various types of reconstruction have been employed in attempts to improve the quality of life after total gastrectomy. The use of a jejunal pouch has been the most common approach, and preservation of the duodenal passage has been recommended in several related studies. The aim of the present study was to investigate the benefit of the use of a segment of transverse colon as a gastric substitute. Methods. Isoperistaltic interposition with a segment of transverse colon was performed after total gastrectomy in 18 patients with gastric malignancies. To clarify the benefits and disadvantages of this technique, a comparison was made between these patients and another 17 patients who underwent jejunal interposition without a pouch. The parameters to be compared included operation time, amount of blood loss, incidence of postoperative complications, and changes in body weight. Results. Postoperative complications were more frequent in the patients reconstructed with the transverse colon, despite a lower incidence of extended lymphadenectomies in this group of patients. No advantage over those treated by the jejunal interposition, in terms of postoperative body weight, was evident during 2 years of follow-up. Conclusion. Although it may be too early to draw definite conclusions, there seems to be little benefit in the use of the transverse colon as a gastric substitute. Received: January 23, 2001 / Accepted: April 24, 2001     

Introduction of minimally invasive surgery for distal and total gastrectomy: a population-based study

BackgroundMinimally invasive gastrectomy has been introduced in Western populations during the last decade. As minimally invasive distal gastrectomy (MIDG) versus total gastrectomy (MITG) are procedures with a different complexity, outcomes may differ. The aim of this population-based cohort study was to evaluate the safety of MIDG and MITG.Materials and methodsAll patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit (2011–2016). Propensity score matching was applied to create comparable groups of patients receiving open distal gastrectomy (ODG) versus MIDG and open total gastrectomy (OTG) versus MITG, using patient and tumor characteristics. Postoperative outcomes and short-term oncological outcomes were appraised.ResultsOf the 1970 eligible patients, 1138 underwent distal gastrectomy and 832 underwent total gastrectomy. For distal gastrectomy, 390 ODG were matched to 288 MIDG patients. Although overall postoperative morbidity and mortality were similar, patients who underwent MIDG encountered less intra-abdominal abscesses (4% vs. 1%, p = 0.039) and wound complications (6% vs. 2%, p = 0.021). The median hospital stay was shorter after MIDGs (9 vs. 7 days, p < 0.001). For total gastrectomy, 323 OTG patients were matched to 258 MITG patients. Overall postoperative morbidity, mortality and hospital stay were similar, whereas the anastomotic leakage rate was higher after MITGs (11% vs. 17%, p = 0.030). Short-term oncological outcomes between both groups were equal for distal and total gastrectomy.ConclusionBenefits of MIG during the early introduction were demonstrated for distal gastrectomy but not for total gastrectomy. An increased anastomotic leakage rate was encountered for MITG.     

Prediction of severe reflux after oesophageal cancer surgery

IntroductionA common and burdensome consequence of oesophagectomy for cancer is reflux. This study aimed to develop a risk prediction model for postoperative reflux using variables available at the time of surgery enabling tailored preventive symptom management.MethodsData were obtained from a nationwide, population-based cohort of 921 adults who underwent oesophagectomy for cancer between 2013 and 2019. Among 569 eligible patients, 383 (67%) participated in the study. Patient and clinical characteristics were retrieved from national health registries and medical records. Postoperative reflux was self-reported 1 year after surgery in the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire module for gastroesophageal symptoms. Multivariable regression models provided odds ratios (OR) with 95% confidence intervals (CI). The performance of the model was evaluated using the area under the receiver-operating characteristic curve.ResultsFemale sex (OR 2.24, 95% CI: 1.00–5.00), preoperative reflux (OR 2.99, 95% CI: 1.61–5.52), and preoperative body mass index ≥30 (OR 2.45, 95% CI: 1.32–4.54) increased the risk of postoperative reflux. A model based on age, sex, preoperative reflux, body mass index, chronic obstructive pulmonary disease, and ventricle substitute predicted 72% of the severe cases.ConclusionFemale sex, preoperative reflux, and preoperative body mass index increased the risk of postoperative reflux. A combination of readily available patient and preoperative clinical variables showed fairly good accuracy in predicting postoperative reflux after oesophagectomy. The clinical risk prediction model may be helpful for early symptom management but needs to be externally validated before wider use.     

Prevalence of Helicobacter pylori infection in gastric remnant after distal gastrectomy for primary gastric cancer

Background. The development of a second primary cancer in the gastric remnant after gastrectomy for early gastric carcinoma is a problem, and eradication of Helicobacter pylori after the operation has been recommended. However, to date, practical indications for H. pylori eradication after gastric cancer surgery have not yet been reported. Methods. We examined H. pylori infection in the gastric remnant after distal gastrectomy for primary gastric cancer. One hundred and nine patients who had had a gastrectomy were studied. Endoscopic findings and results from the urease test, bacteriologic assessment, serological test, and histopathological examination were analyzed. Results. Seventy-one patients (65.1%) were judged to be positive for H. pylori infection. The prevalence of H. pylori infection was found to be significantly decreased in older patients, patients in whom the operation had been performed a long time before examination, patients with symptoms, and patients with severe reflux gastritis. On the other hand, histologically, chronic and acute gastritis correlated significantly with H. pylori infection. H. pylori prevalence was highest in mildly atrophic mucosa and decreased with more extensive atrophic changes of the mucosa. Conclusions. The persistence of H. pylori -related active gastritis in the gastric remnant after gastric cancer surgery was suggested in younger patients with mild atrophic gastritis and without reflux gastritis. These patients may be the best candidates for H. pylori eradication therapy. Received: April 13, 2001 / Accepted: June 18, 2001     

Incidence and treatment outcomes of leakage after gastrectomy for gastric cancer: Experience of 14,075 patients from a large volume centre

IntroductionLeakage is a serious and potentially fatal complication of gastrectomy for gastric cancer. However, comprehensive reports regarding leakage after gastrectomy remain limited. We aimed to evaluate the incidence and treatment outcomes of leakage after gastrectomy for cancer.MethodsWe reviewed the prospectively collected data of 14,075 Patients who underwent gastrectomy for gastric cancer between 2005 and 2017. Outcomes included incidence, risk factors of leakage, and leakage treatment outcomes.ResultsThe median day of leakage detection was postoperative day 7 (range 1–29days). The overall leakage incidence was 1.51% (213/14,075), and the most frequent location was the oesophagojejunostomy (2.07%). Leakage after total gastrectomy was more frequent with minimally invasive surgery (open:1.64%, laparoscopic:3.56%, robotic:5.83%; P < 0.001). Leakage incidence was higher in the surgeon's initial 100 cases than in later cases (2.4 vs. 1.3%; P < 0.001), especially with minimally invasive surgery. Early leakage (within 4 days of surgery) occurred more often after minimally invasive surgery (open:12.7%, laparoscopic:35.4%, robotic:29.0%; P = 0.006). The success rate for initial treatment of leakage was 70.4% (150/213). Surgery after initial treatment failure demonstrated a higher success rate for early leakage than for late leakage (80.0 vs. 22.2%). Among 213 patients who experienced leakage, fifteen patients (7.0%) died, and leakage-related mortality accounted for 38.5% (15/39) of all surgery-related mortality after gastrectomy.ConclusionsLeakage after gastric cancer surgery is associated with high mortality. Improved surgeon experience using minimally invasive techniques is required to reduce the risk of leakage. Surgery is an effective treatment for early leakage, although further studies are needed to establish the most appropriate treatment strategies.     

Laparoscopic side-to-side esophagogastrostomy using a linear stapler after proximal gastrectomy

In order to improve anastomotic procedures, we performed laparoscopic side-to-side esophagogastrostomy, using a linear stapler, after proximal gastrectomy in two patients with gastric cancer located in the upper third of the stomach. The patients' postoperative courses were excellent. During postoperative recovery, the patients experienced very little pain, used no analgesic medications, and never experienced reflux esophagitis. This procedure is technically feasible and is an excellent option, given the less involved anastomotic procedure and better postoperative quality of life compared with these features in end-to-side anastomosis using a circular stapler. Received: February 2, 2001 / Accepted: April 24, 2001     

Sarcopenia is an effective prognostic indicator of postoperative outcomes in laparoscopic-assisted gastrectomy

BackgroundThe association between sarcopenia and postoperative outcomes in patients who undergo laparoscopic-assisted gastrectomy is unclear. We aimed to determine the predictive value of sarcopenia for adverse postoperative outcomes after laparoscopic-assisted gastrectomy for gastric cancer.Materials and methodsWe prospectively collected the clinical data of patients who underwent elective radical laparoscopic-assisted gastrectomy for gastric cancer in two large centers from August 2014 to October 2017. The third lumbar vertebra skeletal muscle index, handgrip strength, and 6-m usual gait speed were measured to diagnose sarcopenia. Subsequently, we aimed to identify the risk factors for postoperative complications.ResultsThe study included 313 patients and 37 (11.8%) patients were classified as sarcopenic. Compared with non-sarcopenic patients, sarcopenic patients were significantly older (P < 0.001), had higher nutritional risk screening 2002 scores (P = 0.013), Charlson comorbidity index (CCI) scores (P = 0.033), and neutrophil to lymphocyte ratio (P = 0.004), and lower body mass index (P < 0.001), preoperative serum albumin (P < 0.001), and hemoglobin (P < 0.001). Sarcopenic patients had higher postoperative complication rate (P = 0.002), longer postoperative hospital stays (P = 0.020) and higher total cost of hospitalization (P = 0.001). Multivariate analysis revealed that CCI score ≥1 (odds ratio [OR]: 2.424, 95% confidence interval [CI]: 1.309–4.487; P = 0.005) and sarcopenia (OR: 2.752, 95% CI: 1.274–5.944; P = 0.010) were independent risk factors for short-term postoperative complications.ConclusionSarcopenia is an independent clinical predictor of short-term postoperative complications after laparoscopic-assisted gastrectomy.     

Long-term effects of jejunal pouch added to Roux-en-Y reconstruction after total gastrectomy

Background. Jejunal pouch reconstruction after total gastrectomy has been demonstrated to ameliorate postgastrectomy symptoms, with the process of adaptation taking several months. In contrast to the short-term effects of pouch reconstruction, there are few reports about the long-term consequences (more than 2 years after surgery). Methods. In this study, 22 patients with jejunal pouch (PRY group) and 12 patients without jejunal pouch (RY group) who survived for more than 2 years without any recurrence and were available for follow-up were compared. Patients in the two groups were compared 2 years after surgery in terms of postgastrectomy symptoms, and improvements in body weight and nutritional parameters. Results. Eating capacity at a single meal compared with that in the pre-illness state was significantly better in the PRY group than in the RY group. The total score on the gastrointestinal symptom rating scale (GSRS) in the PRY group was less than that in the RY group (3.17 vs 5.25). The GSRS score for reflux syndrome in the PRY group was significantly better than that in the RY group. Assessment according to Cuschieri's gradings revealed that the total score in the PRY group was lower than that in the RY group (2.73 vs 5.92). Among the various symptoms examined, the incidence of dietary restriction and that of heartburn were significantly lower in the PRY group. Conclusion. We conclude that, 2 years after total gastrectomy, the pouch reconstruction had alleviated postgastrectomy symptoms to a greater extent than simple Roux-en-Y reconstruction, but the effectiveness could be improved. The long-term effects of pouch reconstruction should be examined more precisely with an adequate and valid scoring system for determining quality of life. Received: May 15, 2001 / Accepted: August 29, 2001     

Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer

Background

Proximal gastrectomy is not routinely performed because it is associated with increased reflux symptoms and anastomotic strictures. The purpose of this study is to describe a novel method of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) for proximal early gastric cancer (EGC), and to evaluate the technical feasibility, safety, and short-term surgical outcomes, especially reflux symptoms, after LPG.

Methods

Retrospective review of the prospective cohort data of 43 patients who presented to a single tertiary hospital from June 2009 through April 2012 and underwent LPG with DTR for proximal EGC. The data of this prospective cohort were analyzed, and the reflux symptoms, clinicopathologic characteristics, surgical outcomes, postoperative morbidities and mortalities, and follow-up findings were analyzed.

Results

The mean surgical time was 180.7 min; mean estimated blood loss, 120.4 mL; mean length of the proximal resection margin, 4.13 cm; mean number of retrieved lymph nodes, 41.2; and mean postoperative hospital stay, 7.1 days. Early complication rate was 11.6 % (n = 5); major complication (grade higher than Clavien-Dindo IIIa) occurred in 1 patient (2.3 %). Late complication rate was 11.6 % (n = 5): 2 patients had esophagojejunostomy stenosis, which was successfully treated with fluoroscopic balloon dilatations; 1, chylous ascites; and 2 had Visick grade II reflux symptoms (4.6 %), managed by medication during the mean follow-up period of 21.6 months.

Conclusion

DTR after LPG is a feasible, simple, and novel reconstruction method with excellent postoperative outcomes in terms of preventing reflux symptoms. Its clinical applicability must be validated by prospective randomized trials.     

Long-term survival after perforation of advanced gastric cancer: Case report and review of the literature

Although the standard operation for early cancer of gastric cardia is proximal gastrectomy followed by jejunal interposition, we recently reported a simple and useful technique for proximal gastrectomy with gastric tube reconstruction. The operative procedures included resection of the proximal two-thirds of the stomach, followed by anastomosis between the esophagus and gastric tube, using a circular stapler (Proximate ILS 25; Ethicon, Cincinnati, OH, USA). The gastric tube was about 20 cm long and 4 cm wide. The patient a 76-year-old man had no reflux symptoms such as heartburn, retrosternal pain, and regurgitation. Endoscopy showed no evidence of reflux esophagitis, including mucosal redness, erosion, and ulceration. Ambulatory 24-h pH monitoring indicated that the pH of the lower esophagus was between 6 and 8 when the patient was upright and between 5 and 7 when he was in the supine position. There were nine reflux episodes during the day, and no reflux episode while he was asleep. The duration of each reflux episode was less than 1 min, and the total reflux time was 1 min in the 12-h day (0.1%). These data indicate that reconstruction by gastric tube may prevent esophageal reflux in patients who have undergone proximal gastrectomy for early cancer of the gastric cardia. Received for publication on Jan. 14, 1998; accepted on Apr. 1, 1998     

Gastric tube reconstruction prevented esophageal reflux after proximal gastrectomy

Although the standard operation for early cancer of gastric cardia is proximal gastrectomy followed by jejunal interposition, we recently reported a simple and useful technique for proximal gastrectomy with gastric tube reconstruction. The operative procedures included resection of the proximal two-thirds of the stomach, followed by anastomosis between the esophagus and gastric tube, using a circular stapler (Proximate ILS 25; Ethicon, Cincinnati, OH, USA). The gastric tube was about 20 cm long and 4 cm wide. The patient a 76-year-old man had no reflux symptoms such as heartburn, retrosternal pain, and regurgitation. Endoscopy showed no evidence of reflux esophagitis, including mucosal redness, erosion, and ulceration. Ambulatory 24-h pH monitoring indicated that the pH of the lower esophagus was between 6 and 8 when the patient was upright and between 5 and 7 when he was in the supine position. There were nine reflux episodes during the day, and no reflux episode while he was asleep. The duration of each reflux episode was less than 1 min, and the total reflux time was 1 min in the 12-h day (0.1%). These data indicate that reconstruction by gastric tube may prevent esophageal reflux in patients who have undergone proximal gastrectomy for early cancer of the gastric cardia. Received for publication on Apr. 27, 1998; accepted on Aug. 19, 1998     

The risk of oesophageal adenocarcinoma after gastrectomy for peptic ulcer disease

BackgroundThe influence of bile reflux in the development of oesophageal adenocarcinoma remains controversial. This was tested in a cohort of patients who had undergone gastrectomy, a procedure often entailed by substantial bile reflux.MethodsA population-based cohort study of patients who had undergone gastrectomy for peptic ulcer disease in 1964–2008 in Sweden. Follow-up for cancer and censoring for death were achieved through linkages to nationwide registries of Cancer and Population, respectively. The number of observed cancer cases in the gastrectomy cohort was divided by the expected number, calculated from the incidence of the entire Swedish population of corresponding age, sex and calendar year. Relative risks were thus presented as standardised incidence ratios with 95% confidence intervals.ResultsAfter exclusion of all person-years the first year after surgery, the final gastrectomy cohort comprised of 19,767 patients. These patients were followed up for a median of 17 years, and contributed with a total of 348,231 person-years at risk. The observed number of patients with oesophageal adenocarcinoma (n = 7) was not higher than the expected (n = 11.6), providing a standardised incidence ratio of 0.6 (95% CI 0.2–1.2). There were no clear differences between sexes, age groups or latency intervals after gastrectomy.ConclusionsGastrectomy for peptic ulcer disease does not appear to increase the risk of oesophageal adenocarcinoma.     

Fracture after gastrectomy for gastric cancer: A long-term follow-up observational study

AimGastrectomy is a known risk factor for decreased bone mass. We aimed to evaluate the cumulative incidence and predictive factors of fracture in gastric cancer patients who underwent gastrectomy.MethodWe retrospectively reviewed the records of 1687 patients who underwent gastrectomy for gastric cancer at our hospital between September 1991 and December 2008. The exclusion criteria were stage IV gastric cancer, history of cancer recurrence, medical conditions that cause osteoporosis and high-energy injury. Fractures at sites considered to be associated with osteoporosis were diagnosed radiologically.ResultsIn total, our analysis included the records of 1131 patients. The incidence of postgastrectomy fracture was 42.1 cases per 1000 person-years. Fractures typically occurred within 3.7 ± 0.5 years postoperatively. The cumulative incidence of fracture was 9.1%, 19.7%, and 37.3% by postoperative year 2, 4, and 6, respectively. During the following years, the cumulative incidence increased slowly, up to a final 40.6%. Multivariate analysis showed that older age (hazard ratio, 1.03; 95% confidence interval, 1.01–1.04) and smoking (hazard ratio, 1.35; 95% confidence interval, 1.05–1.73) were significantly associated with fracture, whereas sex, body mass index, percent weight loss, diabetes mellitus, tumour stage, and type of gastrectomy were not.ConclusionThe cumulative incidence of fracture is high in gastric cancer patients who have undergone gastrectomy, and fracture rate is higher during the early postoperative period. Old age and smoking are independent risk factors for postgastrectomy fracture in these patients. More detailed postoperative surveillance and pharmacological intervention should be considered to prevent fracture.     

Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study

Background

Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer.

Methods

Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression.

Results

In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001).

Conclusions

Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.

     

Complications after proximal gastrectomy with jejunal pouch interposition: report of a case.

We report a rare case of proximal gastrectomy complication as a result of a severe dilatation of a jejunal pouch interposed for reconstruction. A 44-year-old man who had early gastric cancer underwent proximal gastrectomy with a jejunal pouch interposition at our department. Fourteen months after the procedure, he began to complain of left hypochondrial fullness and reflux symptoms. He had difficulty eating and his quality of life (QOL) was markedly impaired. Barium meal revealed severe dilatation of the jejunal pouch. Decompression using a stomach tube and other measures only achieved temporary improvement. 4.5 years later, the dilated jejunal pouch was resected together with apyloroplasty and double tract reconstruction. Six months after this secondary surgery, the patient recorded no further complications. Food intake increased and QOL improved.     

Prognostic analysis of patients with intra-abdominal infectious complications after laparoscopic-assisted and open radical gastrectomy for gastric cancer – A propensity score-matching analysis

BackgroundTo investigate the incidence and prognosis of intra-abdominal infectious complications (IaICs) after laparoscopic-assisted gastrectomy (LAG) and open radical gastrectomy (OG) for gastric cancer.MethodsThe data of patients who underwent radical gastrectomy (LAG and OG) for gastric cancer at the Fujian Medical University Union Hospital from January 2000 to December 2014 were retrospectively reviewed. A 1:1 propensity score matching (PSM) was used to reduce bias. The incidence and prognosis of postoperative IaICs in the two groups were analyzed.ResultsAfter PSM, no significant difference was found in the baseline data between OG (n = 913) and LAG (n = 913). The incidence of IaICs after OG and LAG was 4.1% and 5.1%, respectively (p = 0.264). The Cox multivariate analysis showed that IaICs were an independent risk factor for overall survival (OS) of patients undergoing gastrectomy (hazard ratio [HR]: 1.65, p < 0.001). Further, LAG was an independent protective factor for OS among the patients with IaICs (HR: 0.54, p = 0.036), while tumor diameter of ≥50 mm (p = 0.01) and pathological TNM stage III (p < 0.001) were independent risk factors. The 5-year OS rate was higher in the patients with IaICs who underwent LAG than in those who underwent OG (51.1% vs. 32.4%, p = 0.042). The prognostic nutritional index was similar in both groups before surgery (p = 0.220) but lower on the first, third, and fifth days after OG than after LAG (p < 0.05).ConclusionsCompared to OG, LAG can improve the prognosis of patients with postoperative IaICs and is therefore recommended for patients at a high risk for IaICs.