Comparison of Gastric Fundus Invagination and Gastric Greater Curvature Plication for Weight Loss in a Rat Model of Diet-Induced Obesity

Background

Gastric fundus invagination (GFI) is a novel weight loss procedure. The gastric fundus is invaginated inside the gastric lumen and anastomosed to the gastric antrum. In gastric plication (GP), the greater curvature is plicated inside the gastric lumen leaving a narrow gastric channel for food passage. This study compares GFI to GP in a diet-induced obesity rat model.

Methods

Twenty Long-Evans male rats were fed a 60 % high fat diet for 6 weeks. At 14 weeks of age, the rats underwent either GFI (N?=?10) or GP (N?=?10) surgery. Body weight and food intake were measured for 6 weeks. Serum adipokines and ghrelin hormone were assayed. Six weeks after surgery, all rats were euthanized and the stomachs examined. The two-sample t test was used to compare the results between the two groups.

Results

All GFI rats had an intact fundus invagination at 6 weeks following surgery. The greater curvature plication unfurled in three out of ten GP rats. Part of the fundus herniated through the plication suture line in one GP rat. There was no significant difference between the mean percent weight change for the GFI (4.2?±?4.1 %) and GP (8.8?±?6.0 %) groups. There was no difference in food intake between both groups. GFI was associated with a significant lower fasting ghrelin levels (101.1?±?13.1 versus 137.3?±?27.4; p?=?0.044) compared with GP.

Conclusions

GFI offers a more effective and more durable surgical alternative for weight loss than GP.     

Gastrectomy in Advanced Gastric Cancer Effectively Palliates Symptoms and May Improve Survival in Select Patients

Background

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

Methods

We reviewed 210 locally advanced or metastatic gastric cancers (1992–2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N?=?99), exploration without resection (N?=?66), and no surgery (N?=?45).

Results

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p?<?0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR?=?0.175). Resolution of symptoms (p?<?0.001, Hazards Ratio (HR)?=?0.09) and preoperative nausea/vomiting (p?=?0.017, HR?=?0.55) improved survival, while linitis plastica (p?=?0.035, HR?=?4.05) and spindle cell morphology (p?=?0.011, HR?=?1.98) were predictors of poor survival in patients undergoing resection.

Conclusions

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.     

Revision Surgery for Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Background

This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up.

Methods

This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n?=?9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n?=?13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n?=?2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n?=?5) are patients who underwent gastric plication and placing of a silicon ring.

Results

The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation.

Conclusions

Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.     

Predictors of prolonged intensive care unit stay in patients undergoing coronary surgery

Background

We aimed to investigate the factors affecting the length of intensive care unit (ICU) stay in patients undergoing isolated on-pump coronary artery bypass (CABG). We also aimed to evaluate effective factors on morbidity, mortality, and survival among patients with prolonged ICU stay.

Methods

Between January 2002 and December 2009, a total of 1,657 patients underwent isolated on-pump CABG in our clinic. Prolonged ICU stay (>2 days) was present in 532 patient (32.1 %).

Results

Diabetes (OR 1.49, P?=?0.006), hypertension (OR 1.37, P?=?0.029), chronic obstructive pulmonary disease (OR 9.06, P?P?P?P?=?0.023), prolonged inotropic support (OR 40.40, P?P?=?0.022), postoperative renal insufficiency (OR 4.50, P?=?0.004), postoperative atrial fibrillation (OR 8.00, P?3 units) (OR 3.23, P?=?0.007) were the independent predictive factors of prolonged ICU stay (>2 days). Postoperative mortality rate was 7 % (n?=?37) and 2.3 % (n?=?26) in patients with length of ICU stay >2 days and length of ICU stay ≤2 days (P?2 days (P?Conclusions Postoperative mortality was higher in patients with prolonged ICU stay. Mean follow-up was shorter in patients with prolonged ICU stay.     

Is Routine Preoperative Upper GI Endoscopy Needed Prior to Gastric Bypass?

Background

In Finland, upper GI endoscopy (UGI) prior to bariatric surgery is routine in all but one hospital performing bariatric surgery. However, UGI is an unpleasant investigation for the patient and requires resources. Helicobacter pylori (HP) can be tested from blood and cannot be considered as an indication for UGI. We wanted to identify the most common findings in UGI and see if the findings influenced the decision to operate or if they even canceled the operation.

Methods

We evaluated retrospectively the data of 412 patients undergoing preoperative UGI in Vaasa Central Hospital in the years 2006–2010.

Results

UGI was considered normal in 191 (55.8 %) patients. The most common findings were hiatal hernia in 25.4 % (n?=?87); gastritis, 13.7 % (n?=?47); and esophagitis, 13.2 % (n?=?45). Also benign polyps, 6.7 % (n?=?23), and ulcers, 2.9 % (n?=?10), were detected. One 0.5-cm esophageal leiomyoma was found, but no malignant lesions. Histology was found normal in 185 (54.1 %) patients. HP was found in 12.0 % (n?=?41) of patients.

Conclusions

In this study, all the findings were benign and mild. The findings did not influence the operative plan. The most common findings were hiatal hernia and esophagitis which may be considered contraindications for sleeve gastrectomy, but not for gastric bypass. Our results do not support the performance of routine preoperative UGI prior to gastric bypass.     

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

Introduction

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

Patients and methods

From 2001–2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n?=?293; squamous cell cancer (SCC), n?=?111; gastric cancer, n?=?203) after preoperative treatment (n?=?281) or primary resection (n?=?326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

Results

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p?<?0.001) but also with a higher complication rate (p?=?0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p?=?0.010; SCC, p?=?0.023; gastric cancer, p?=?0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9–59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6–27.0) and primary resected patients with 20.8 months (95 % CI, 17.7–23.9; p?=?0.002). AEG (p?=?0.012) and gastric cancer (p?=?0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9–16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7–46.0; p?=?0.012).

Conclusion

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.     

Standardization of the Fully Stapled Laparoscopic Roux-en-Y Gastric Bypass for Obesity Reduces Early Immediate Postoperative Morbidity and Mortality: A Single Center Study on 2606 Patients

Background

Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality.

Methods

We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%).

Results

There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14–73), mean BMI 41.44 kg/m² (range, 23–75.5). The mean hospital stay was 3.35 days (range 2–71). Mean total operative time was 63 min (range 35–150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n?=?89, 3.42%), intestinal obstruction (n?=?9, 0.35%), anastomotic leak (n?=?5, 0.19%) and others (n?=?47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure.

Conclusion

The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.     

Routine Gastrostomy Tube Placement in Gastric Bypass Patients: Impact on Length of Stay and 30-Day Readmission Rate

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. Current average length of hospital stay (LOS) after RYGB is 2–3 days and 30-day readmission rate is 8–13 %. The aim of our study is to evaluate the effect of routine gastrostomy tube placement in perioperative outcomes of RYGB patients.

Methods

Between January 2008 and December 2010, a total of 840 patients underwent RYGB at our institution. All RYGB patients had gastrostomy tube placed, which was kept for 6 weeks. A retrospective review of a prospectively collected database was performed for all RYGB patients, noting the outcomes and complications of the procedure.

Results

Average LOS in our patient population was 1.1 days (range, 1–14 days), and 824 (98.3 %) patients were discharged on postoperative day 1. Readmissions within 30 days after the index RYGB was observed in 31 (3.7 %) patients. Reasons included abdominal pain (n?=?14), nausea/vomiting (n?=?6), gastrostomy tube-related complications (n?=?5), chest pain (n?=?3), allergic reaction (n?=?1), urinary tract infection (n?=?1), and dehydration (n?=?1). Of these readmitted patients, nine (1.1 %) patients required reoperations due to small bowel obstruction (n?=?5), perforated anastomotic ulcer (n?=?1), anastomotic leak (n?=?1), subphrenic abscess (n?=?1), and appendicitis (n?=?1).

Conclusions

Routine gastrostomy tube placement in the gastric remnant at the time of RYGB seems to have contributed to our short LOS and low 30-day readmission rate.     

The contributions of First Nations ethnicity, income, and delays in surgery on mortality post-fracture: a population-based analysis

Summary

We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture.

Introduction

First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture.

Methods

Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged ≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996–2004 (population 1, n?=?63,081), and the hip, 1987–2002(Population 2, n?=?41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year.

Results

Population 1: First Nations ethnicity was associated with an increased mortality risk of 30–53 % for each fracture type. Lower income was associated with an increased mortality risk of 18–26 %. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95 % confidence interval (CI) 1.07–1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05–1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p?≤?0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95 % CI 1.03–1.27), or surgery delay of 2–3 days (OR 1.34, 95 % CI 1.18–1.52) or ≥4 days (OR 2.35, 95 % CI 2.07–2.67).

Conclusion

A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay >2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.     

Patterns of Consultation and Treatment of Patients with Hepatocellular Carcinoma Presenting to a Large Academic Medical Center in the US

Background

Management of hepatocellular carcinoma (HCC) often involves many subspecialist providers, as well as a broad range of treatment options. This study sought to evaluate referral and treatment patterns among patients with HCC at a large academic medical center.

Methods

Data from our cancer registry between 2003–2011 were abstracted on 394 patients who were primarily diagnosed/treated for HCC at Johns Hopkins Hospital (JHH); data on patients who were diagnosed/treated with HCC elsewhere and who received secondary treatment at JHH (n?=?391) were also abstracted for comparison purposes.

Results

Among the main cohort, the most common specialties to be consulted were surgery (n?=?225, 57.1 %), gastroenterology (n?=?225, 57.1 %), and interventional radiologist (n?=?206, 52.3 %), while only 96 (24.4 %) were referred to medical oncology. Factors associated with surgical consultation included younger age (odds ratio (OR) 3.35, 95 % CI 1.62–6.92), tumor size <5 cm (OR 1.82, 1.09–3.02), and unilobar disease (OR 2.94, 1.31–6.59) (all P?<?0.05). Patients initially diagnosed/treated elsewhere had larger tumors (4 vs. 6 cm), bilateral disease (19.2 vs. 26.8 %), and were more likely to be seen by interventional radiology (all P?<?0.05)

Conclusions

Most patients were seen by surgeons, gastroenterologists, or interventional radiologists, with only a minority being seen by medical oncologists. Referral patterns depended on patient-level factors, as well as extent of disease.     

Prognostic Factors for Postoperative Morbidity and Tumour Response After Neoadjuvant Chemoradiation Followed by Resection for Rectal Cancer

Background and Purpose

In patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by rectal resection, postoperative morbidity is a significant clinical problem. Pathologic complete tumour response seems to give the best prognosis in the long term. Little is known about the factors that are associated with postoperative complications and pathologic complete response. The aim of this retrospective study was to identify and describe these factors.

Methods

Ninety-nine consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation (50 Gy and capecitabine) followed by surgery at our institute between January 2007 and May 2012 were identified. Postoperative complications were graded according to the Clavien-Dindo classification. Pathologic tumour response was categorized as complete response or no/partial response.

Results

Postoperative complications occurred in 68 patients (69 %) and grade 3–5 complications in 25 patients (25 %). The 30-day and 90-day mortality were 1 % (n?=?1) and 2 % (n?=?2), respectively. A young age (p?=?0.021) and a preoperative or postoperative blood transfusion (p?=?0.015) independently predicted complications. Intraoperative or postoperative blood transfusion (p?=?0.007) and ypT0-1 stage (p?=?0.037) were independent predictors for grade 3–5 complications. Complete response rate was 22 % (n?=?22); 4 % (n?=?4) of patients showed no response. No independent factors predicting complete response were found.

Conclusions

Neoadjuvant chemoradiation followed by rectal resection is associated with significant postoperative morbidity but minimal postoperative mortality. A complete response rate of 22 % was achieved.     

Serum Markers for Predicting Abdominal Surgery Outcomes in Patients with Cirrhosis

Background

Determinants of adverse events for cirrhotic patients undergoing abdominal surgery have not been adequately assessed. Child–Turcotte–Pugh (CTP) and Model for End-Stage Liver Disease (MELD) have estimated perioperative outcomes with inconsistent results. Our study sought to combine novel serum markers with CTP and MELD to improve prognostication of 30-day postoperative mortality or liver transplant in cirrhotic patients undergoing abdominal surgery.

Methods

A review was performed on 120 cirrhotic patients undergoing nonhepatic abdominal surgeries at Mount Sinai Medical Center from 2001–2011. Preoperative serum markers were evaluated by logistic regression and receiver–operator characteristics. Prognostic ability of scoring systems was assessed using Youden’s J statistic (J).

Results

Albumin and hematocrit were independently predictive of 30-day mortality or transplant with optimal cutoff values of albumin at <3.05 mg/dl and hematocrit at <35.55 %. Adding these criteria to CTP>A, CTP>B, MELD?≥?10, MELD?≥?15, and MELD?≥?20 improved sensitivity and specificity by an average of 6.1 and 32.1 %, respectively. The highest J values resulted from combining novel criteria with CTP>A (sensitivity, 80 %; specificity, 82 %; p?<?0.01; J, 0.63) and MELD?≥?10 (sensitivity, 63 %; specificity, 90 %; p?<?0.01; J, 0.53).

Conclusion

Augmenting CTP and MELD with albumin and hematocrit significantly improved the identification of cirrhotic patients at risk of 30-day mortality or transplantation following nonhepatic abdominal surgery.     

Long-Term Effects of Gastric Stimulation on Gastric Electrical Physiology

Introduction

This study evaluates the modeling of gastric electrophysiology tracings during long-term gastric electrical stimulation for gastroparesis. We hypothesized that serosal electrogastrogram may change over time representing gastric remodeling from gastric stimulation.

Patients

Sixty-five patients with gastroparesis underwent placement of gastric stimulator for refractory symptoms. Mean age at initial stimulator placement was 44 years (range, 8–76), current mean age was 49, and the majority of the subjects were female (n?=?51, 78 %). Only a minority had diabetes-induced gastroparesis (n?=?16, 25 %); the remainder were either idiopathic or postsurgical.

Methods

At the time of stimulator placement, electrogastrogram was performed after the gastric leads were placed but before stimulation was begun. Patients underwent continuous stimulation until pacer batteries depleted. At the time of replacement, before the new pacemaker was attached, electrogastrogram was again performed.

Results

After a mean of 3.9 years of stimulation therapy, the mean of baseline frequency before stimulation therapy was 5.06 cycles/min and declined to 3.66 after replacement (p?=?0.0000002). The mean amplitude was 0.33 mV before stimulation therapy and decreased to 0.31 mV (p?=?0.73). The frequency/amplitude ratio was 38.4 before stimulation therapy and decreased to 21.9 (p?=?0.001).

Conclusion

Long-term gastric electrical stimulation causes improvement in basal unstimulated gastric frequency to near normal.     

Prevalence and risk factors of radiographic vertebral fractures in elderly Chinese men and women: results of Mr. OS (Hong Kong) and Ms. OS (Hong Kong) studies

Summary

This study investigated the prevalence of radiographic vertebral fractures using Genant’s semiquantitative (SQ) scoring system in elderly Chinese men (n?=?2,000; mean age, 72.4 years) and women (n?=?2,000; mean age, 72.6 years). Vertebral deformities had similar prevalence in elderly men (14.9 %) and women (16.5 %). Majority of the deformities in men were mild (9.9 %, grade?=?1). The prevalence of vertebral fractures (grade?≥?2) was 5.0 % among men and 12.1 % among women.

Introduction

Vertebral fracture is a serious consequence of osteoporosis and is often under-diagnosed. Researches on different ethnicities and territories to estimate the prevalence of vertebral fractures and to identify the risk factors are necessary.

Methods

Mr. OS (Hong Kong) and Ms. OS (Hong Kong) represent the first large-scale cohort studies ever conducted on bone health in elderly Chinese men (n?=?2,000) and women (n?=?2,000). The current study investigated the prevalence of radiographic vertebral fractures in these subjects using Genant’s SQ scoring system and identified risk factors for vertebral fractures.

Results

The radiographs of all men (mean age, 72.4 years) and women (mean age, 72.6 years) were obtained. Six hundred twenty-seven subjects (15.7 %) had at least one vertebral deformity (SQ grade?≥?1), including 297 men (14.9 %) and 330 women (16.5 %, p?=?0.151). Three hundred forty-two participants (8.6 %) were defined as having at least one vertebra fracture (SQ grade?≥?2), consisted of 100 men (5.0 %) and 242 women (12.1 %, p?<?0.001). Older age, lower bone mineral density, lower physical activity, lower grip strength, fracture history, and low back pain were significantly associated with higher vertebral fracture rate for both men and women.

Conclusion

Vertebral deformity had similar prevalence in older men and women, while vertebral fracture was more common in women. Majority of deformities in men was mild. The vertebral deformity prevalence of women from this study is similar to previous reports of other East Asian women and Latin American women.     

Simultaneous Versus Staged Bilateral Total Knee Arthroplasty

Background

An important source of debate in many orthopaedic practices is the choice of performing simultaneous or staged bilateral total knee arthroplasty.

Questions/Purpose

The objective of this meta-analysis is to compare simultaneous bilateral with staged bilateral total knee arthroplasty for peri-operative complication rates, infection rates and mortality outcomes.

Methods

All relevant citations were retrieved from MEDLINE, EMBASE, COCHRANE databases and the unpublished literature. Included studies were assessed for methodological quality and abstracted data was conducted independently by two reviewers. Data was categorized into subgroups and pooled using the DerSimonian and Laird’s random effects model.

Results

A total of 18 articles were identified from 873 potentially relevant titles and selected for inclusion in the primary meta-analyses. The incidence of mortality was significantly higher in the simultaneous group at 30 days (RR [relative risk] 3.67, 95% confidence interval [CI] 1.68–8.02, p?=?0.001, I ²?=?59%, n?=?67,691 patients), 3 months (RR 2.45, 95% CI 2.15–2.79, p?<?0.00001, I ²?=?0%, n?=?66,142 patients) and 1 year (RR 1.85, 95% CI 1.66–2.06, p?<?0.001, I ²?=?0%, n?=?65,322 patients) after surgery. However, there were no significant differences between the two groups in regards to in-hospital mortality rates (R 1.18, 95% CI 0.74–1.88, p?=?0.48, I ²?=?0%, n?=?33,814 patients). In addition, there was no increased risk of deep vein thrombosis, cardiac complication, and pulmonary embolism or infection rates in either comparison group.

Conclusions

The results of the analysis suggest that simultaneous bilateral total knee arthroplasty has a significantly higher rate of mortality at 30 days, 3 months and 1 year after surgery, but similar infection and complication rates in comparison to staged bilateral total knee arthroplasty.     

Clinical Outcomes and Prognostic Factors After Surgery for Non-Occlusive Mesenteric Ischemia: a Multicenter Study

Background

To date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI.

Patients and Methods

Clinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n?=?51) were divided into two groups: group I (n?=?28) consisted of patients who survived, and group II (n?=?23) consisted of patients who did not survived. Prognostic factors were compared between the two groups.

Results

NOMI surgery represented 0.04 % of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45 %. Hemodialysis was a significant negative prognostic factor (p?=?0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5?±?3.6 and 85.2?±?4.1, respectively (p?Conclusions Currently, NOMI surgery has a 45 % mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.     

Noncurative Gastrectomy for Gastric Adenocarcinoma Should only be Performed in Highly Selected Patients

Background

The benefit of surgical resection in patients with incurable gastric adenocarcinoma is controversial.

Methods

A total of 289 patients who presented with advanced or metastatic gastric cancer from 1995 to 2010 were retrospectively reviewed.

Results

Ten patients (3.5 %) required emergent surgery at presentation and were excluded from further analyses. Patients who underwent nonemergent surgery at presentation (n = 110, 38.1 %) received either gastric resection (group A, n = 46, 42 %) or surgery without resection (group B, n = 64, 58 %). Procedures in group A included distal gastrectomy (n = 25, 54 %), total gastrectomy (n = 17, 37 %), and proximal/esophagogastrectomy (n = 4, 9 %). Procedures in group B included laparoscopy (n = 17, 27 %), open exploration (n = 25, 39 %), gastrostomy and/or jejunostomy tube (n = 12, 19 %), and gastrojejunostomy (n = 10, 16 %). Group A required a stay in the intensive care unit or additional invasive procedure significantly more often than group B (15 vs. 2 %, p = 0.009). Four patients in group A (8.7 %) and three patients in group B (4.7 %) died within 30 days of surgery (p = 0.45). When the 110 patients who underwent nonemergent surgery (groups A and B) were compared to nonoperatively managed patients (group C, n = 169, 58 %), median overall survival did not significantly differ (8.6 vs. 9.2 vs. 7.7 months; p > 0.05). Three patients in group B (4.7 %) and three in group C (1.8 %) ultimately required an operation for their primary tumor.

Conclusions

Patients with gastric adenocarcinoma who present with advanced or metastatic disease not amenable to curative resection infrequently require emergent surgery. Noncurative resection is associated with significant perioperative morbidity and mortality as well as limited overall survival, and should therefore be performed judiciously.     

Laparoscopic Sleeve Gastrectomy (LSG)—A Good Bariatric Option for Failed Laparoscopic Adjustable Gastric Banding (LAGB): A Review of 90 Patients

Background

Laparoscopic adjustable gastric banding (LAGB) is one of the most frequently performed bariatric surgeries. Even with a high failure rate, revisional procedures such as re-banding or laparoscopic Roux-en-Y gastric bypass (LRYGB) were commonly performed. Recently, conversions of LAGB to laparoscopic sleeve gastrectomy (LSG) were reported. We will review our experience on this conversion.

Methods

Between February 2007 and January 2012, 800 patients underwent LSG, with 90 as a revisional procedure for failed LAGB. A retrospective review of a prospectively collected database was performed. Data were collected through routine follow-up and weight loss data were also obtained through self-reporting via the Internet. Demographics, complications, and percentage of excess weight loss (%EWL) were determined.

Results

A total of 90 patients underwent LSG as a revisional procedure, comprising of 77 women and 13 men with a mean age of 41 years (22 to 67), a mean body mass index of 42 kg/m² (26 to 58). Among them, 15.5 % had diabetes mellitus, 35.5 % had hypertension, 20.0 % had hyperlipidemia, and 18.8 % had obstructive sleep apnea. The mean operative time was 112 min (50 to 220) and mean hospital stay was 4.2 days (1 to 180). Operative complications included 5.5 % leak and 4.4 % hemorrhage or gastric hematoma. There was no postoperative mortality. The mean postoperative %EWL was 51.8 % (n?=?82), 61.3 % (n?=?60), 61.6 % (n?=?45), 53.0 % (n?=?30), 55.3 % (n?=?20), and 54.1 % (n?=?10) at 6, 12, 18, 24, 36, and 48 months, respectively.

Conclusions

LSG after LAGB yields a positive outcome with higher complication rates than for primary LSG. We advocate this procedure as a good bariatric option for failed LAGB.     

Colorectal Surgery After Kidney Transplantation: Characteristics of Early vs. Late Posttransplant Interventions

Background

The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period.

Methods

We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions.

Results

We identified 45 patients aged 31–77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n?=?9) had more cases of ischemic colitis (44 vs. 6 %, p?=?0.01), emergent operations (100 vs. 33 %, p?=?0.0003), blood transfusion (78 vs. 31 %, p?=?0.02), longer length of stay (23.2?±?12 vs. 11.7?±?10 days, p?=?0.02), and higher mortality rate (33 vs. 6 %, p?=?0.05 compared to the late group (n?=?36)). There were no significant differences in major complications, reoperations, or readmissions.

Conclusions

Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.     

Postoperative Complications and Survival after Gastric Cancer Surgery in Patients Older than 80 Years of Age

Background

This study sought to identify and evaluate the risk factors of postoperative complications, prognostic factors, and appropriate surgical strategies in elderly patients undergoing surgery for gastric cancer.

Methods

The medical records of 396 radical gastrectomies conducted from January 2006 to December 2011 were retrospectively reviewed. Surgical results and survival rates were assessed for 60 elderly patients (aged?≥?80 years) and 336 non-elderly patients (aged?<?80 years). The study groups were compared with respect to clinicopathological findings, surgical outcomes, and survival.

Results

Elderly patients underwent gastrectomies with shorter operation time, showed less extensive lymphadenectomy, and had a significant difference in overall survival compared with non-elderly patients, although there was no difference in cause-specific survival among patients receiving curative resection. No significant risk factors affecting postoperative complications were identified in the elderly patients. Number of comorbidities (≥2) (HR, 5.30; 95 % CI, 1.11–25.32; P?=?0.037) and TNM stage (≥II) (HR, 12.97; 95 % CI, 1.60–105.38; P?=?0.017) were identified as independent prognostic factors in the elderly patients receiving curative resection.

Conclusions

Age is not an independent prognostic factor for patients receiving curative resection for gastric cancer. Multiple comorbidities may also influence the prognosis of elderly patients. Careful follow-up would improve overall survival for elderly patients.