Visual evaluation of the larynx and hypopharynx during esophagogastroduodenoscopy: a safety and feasibility study

Background

The larynx and hypopharynx are common sites for head and neck cancer, which shares many risk factors with upper digestive tract disease. Patient survival with malignancies depends on stage at the time of diagnosis. Endoscopic screening of the hypopharynx is neither routinely performed in clinical practice nor has it been evaluated in a formal study.

Methods

This is a prospective pilot study of patients undergoing routine EGD. Demographic data were collected from patients prior to the procedure. All patients in the study underwent an EGD and prior to performing the standard portion of the EGD procedure, the endoscopist evaluated the larynx and hypopharynx with both white light endoscopy (WLE) and narrow band imaging (NBI). Details of the procedure, including ability to see all anatomic structures, time spent, complications, and findings, were recorded.

Results

A total of 111 patients were included in the study. The exam of the laryngopharynx was completed in 87 % of patients (97/111). Reasons for incomplete exam included intubated patients (2/14), inadequate sedation (9/14), and inability to see the entire hypopharynx (3/14). The mean time of the WLE was 20.2 s, while the NBI evaluation took 15.6 s for a mean and 35.8 s for the entire exam of the larynx and hypopharynx. Minor procedural complications occurred in 3/11 (2.7 %) of the patients and included hypotension, tachycardia, and hypoxia. There were 6 patients who had hypopharyngeal abnormalities seen on both WLE and NBI (5.4 %) and were subsequently referred to otolaryngology. Of the six referrals, one patient had a vocal cord biopsy showing leukoplakia, while the others were deemed normal anatomic variants.

Conclusions

Evaluation of the hypopharynx can be accomplished by gastrointestinal endoscopists at the time of EGD in the vast majority of patients in a safe manner while adding only about 35 s to the overall exam time.

     

Postoperative Bleeding and Leakage After Sleeve Gastrectomy: a Single-Center Experience

Background

Sleeve gastrectomy is being performed increasingly, mainly due to its low morbidity and mortality, but complications do occur. The aim of this study was to evaluate bleeding and leakage rates of primary and revisional sleeve gastrectomy in a personal series of 664 consecutive patients.

Methods

Medical charts of all patients undergoing a primary or revisional sleeve gastrectomy between August 2008 and December 2014 were reviewed retrospectively. Subgroup analysis compared bleeding in patients after reduced port versus multiport technique and primary versus revisional sleeve gastrectomy.

Results

A total of 664 sleeve gastrectomies (489 women and 175 men) were performed. Mean age and body mass index were 36.03?±?11.4 years and 42.9?±?8.3 kg/m², respectively. Mean operative time was 58.5?±?20.0 min, with a 0.15 % conversion rate. Mean hospital stay was 2.1?±?0.3 days. The overall 30-day complication rate was 7.5 %. Thirteen patients sustained postoperative bleeding (2 %), three of whom required reoperation (0.5 %). Staple line leakage and mortality were both nil in this series. No difference in postoperative complications was found between the subgroups.

Conclusions

In this single-surgeon, single-center experience, sleeve gastrectomy was a safe and effective bariatric procedure with a low complication rate. Staple line reinforcement by oversewing was associated with low bleeding complications and no leakage. The majority of patients with postoperative bleeding could be managed conservatively. In our experience, reduced port technique and revisional sleeve gastrectomy had similar complication rates compared to multiport and primary sleeve gastrectomy.

     

Prevalence of Barrett’s Esophagus in Bariatric Patients Undergoing Sleeve Gastrectomy

Background

The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett’s esophagus after sleeve gastrectomy are present in the current literature.

Purpose

The purpose of this paper was to report the incidence of Barrett’s esophagus in patients submitted to sleeve.

Material and Methods

Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett’s esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.

Results

Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2 %). Erosive esophagitis was found in 38 patients (15.5 %), and histological examination confirmed Barrett’s esophagus in 3/231 cases (1.2 %) with presence of intestinal metaplasia.

Conclusion

Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett’s esophagus.

     

Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy (R-Duet TLDG) Using a Three-Port to Treat Gastric Cancer

Background

Gastric cancer is commonly treated via minimally invasive surgery. The present study explored the feasibility of right-side approach-duet (R-duet) totally laparoscopic distal gastrectomy using a three-port compared with a four- or five-port.

Methods

A total of 251 patients who underwent curative totally laparoscopic distal gastrectomy for gastric cancer (72 R-duet, 74 four-port, and 105 five-port) at the Catholic Medical Center were enrolled. All operations were performed using conventional laparoscopic instruments. The clinicopathological characteristics, operative details, and postoperative short-term outcomes were analyzed retrospectively.

Results

The clinicopathological characteristics did not differ significantly among the groups, except that the N stage was higher in the five-port group. The operating time was significantly longer in the four-port than the R-duet group (R-duet, four-port, and five-port 148.2 ± 30.7, 162.4 ± 30.6, and 159.9 ± 31.5 min, respectively; p = 0.024). The estimated blood loss did not differ significantly. Postoperatively, the times to flatus and to soft diet consumption and the hospital stay were significantly longer in the five-port group. The extent of postoperative complications did not differ among the groups.

Conclusions

R-duet totally laparoscopic distal gastrectomy is a reliable form of reduced-port surgery when used to treat gastric cancer; no special instruments are required.

     

Analgesic Effect of Intraperitoneal Bupivacaine Hydrochloride After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Background

The indications for sleeve gastrectomy as a primary procedure for the surgical treatment of morbid obesity have increased worldwide. Pain is the most common complaint for patients on the first day after laparoscopic sleeve gastrectomy. There are various methods for decreasing pain after laparoscopic sleeve gastrectomy such as the use of intraperitoneal bupivacaine hydrochloride. This clinical trial was an attempt to discover the effects of intraperitoneal bupivacaine hydrochloride on alleviating postoperative pain after laparoscopic sleeve gastrectomy.

Methods

In general, 120 patients meeting the inclusion criteria were enrolled. Patients were randomly allocated into two interventions and control groups using a balanced block randomization technique. One group received intraperitoneal bupivacaine hydrochloride (30 cm³), and the other group served as the control one and did not receive bupivacaine hydrochloride. Diclofenac suppository and paracetamol injection were administered to both groups for postoperative pain management.

Results

The mean subjective postoperative pain score was significantly decreased in patients who received intraperitoneal bupivacaine hydrochloride within the first 24 h after the surgery; thus, the instillation of bupivacaine hydrochloride was beneficial in managing postoperative pain.

Conclusions

The intraoperative peritoneal irrigation of bupivacaine hydrochloride (30 cm³, 0.25%) in sleeve gastrectomy patients was safe and effective in reducing postoperative pain, nausea, and vomiting (IRCT2016120329181N4).

     

Surgical and Survival Outcome Following Truly Palliative Gastrectomy in Patients with Incurable Gastric Cancer

Background and objectives

Gastrectomy is sometimes performed even in patients with incurable factors, particularly when they have urgent symptoms. The aim of this study was to clarify the clinicopathological characteristics of patients undergoing palliative gastrectomy and to identify prognostic factors.

Methods

This study included consecutive 137 gastric cancer patients with urgent symptoms who underwent gastrectomy with macroscopic residual tumor at Shizuoka Cancer Center. Clinicopathological characteristics and surgical outcomes were investigated. In addition, we used the Cox proportional hazards model to identify independent prognostic factors.

Results

Of 137 patients, urgent symptoms were bleeding in 58 patients and stenosis in 112 patients. Postoperative complications were observed in 58 patients (42 %). Chemotherapy was given after surgery in 94 patients (70 %). Median survival time for all patients was 9.9 months, and was longer in patients receiving chemotherapy (11.1 months) than in those not receiving chemotherapy (6.8 months; p = 0.002). Multivariate analysis identified macroscopic type (hazard ratio, 0.471; 95 % confidence interval, 0.364–0.927) as an independent prognostic factor.

Conclusions

The postoperative complication rate was high and survival outcome was poor in patients undergoing palliative gastrectomy. Postoperative chemotherapy may carry a better survival outcome, so we should try to give chemotherapy after palliative gastrectomy.

     

Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer

Introduction

Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients.

Methods

A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil?) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded.

Results

Overall, DST was performed in 60 patients [total gastrectomy (81.7 %, n?=?49/60), proximal gastrectomy (10.0 %, n?=?6/60), and completion gastrectomy (8.3 %, n?=?5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0 %), and 6 patients (10.0 %) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7 %, n?=?31/60), laparoscopic (43.3 %, n?=?26/60), or robotic (5.0 %, n?=?3/60). Anastomotic leak occurred in 6.7 % (n?=?4/60), while stricture independent of leak was identified in 19.0 % (n?=?11/58) of patients. Complications occurred in 38.3 % (n?=?23/60) of patients, of which 52 % were classified as Clavien-Dindo grades III–V complications.

Conclusion

In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

     

Additional surgery for non-curative resection after endoscopic submucosal dissection for gastric cancer: a retrospective analysis of 200 cases

Purpose

Endoscopic submucosal dissection is recommended for early gastric cancer with a low risk of lymph node metastasis. When the pathological findings do not meet the curative criteria; then, an additional gastrectomy with lymph node dissection is recommended. However, most cases have neither lymph node metastasis nor a local residual tumor during an additional surgery.

Methods

This was a single-institutional retrospective cohort study, analyzing 200 patients who underwent an additional gastrectomy after non-curative endoscopic submucosal dissection from January 2005 to October 2015. We reviewed the patients’ clinicopathological data and evaluated the predictors for the presence of a residual tumor.

Results

Histopathology revealed lymph node metastasis in 15 patients (7.5 %) and a local residual tumor in 23 (11.5 %). A multivariable analysis revealed macroscopic findings (flat/elevated type) (p = 0.011, odds ratio = 4.63), lymphatic invasion (p < 0.0001, odds ratio = 14.2), and vascular invasion (p = 0.04, odds ratio = 4.00) to be predictors for lymph node metastasis. A positive vertical margin (p = 0.0027, odds ratio = 3.26) and horizontal margin (p = 0.0008, odds ratio = 5.74) were predictors for a local residual tumor. All cases with lymph node metastasis had lymphovascular invasion with at least one other non-curative factor.

Conclusions

The risk of a residual tumor can, therefore, be estimated based on the histopathology of endoscopic submucosal dissection samples. Lymphovascular invasion appears to be a pivotal predictor of lymph node metastasis.

     

Comparison of endoscopic resection and gastrectomy for the treatment of early gastric cancer: a meta-analysis

Background

Endoscopic resection methods, including endoscopic mucosal resection and endoscopic submucosal dissection, have become standard treatment modalities for patients with early gastric cancer (EGC) and absolute indications, with en bloc resection being more frequent with the latter. Endoscopic resection, however, has been associated with higher recurrence and metachronous cancer rates than gastrectomy. This meta-analysis compared the efficacy and safety of endoscopic resection and gastrectomy for EGC.

Methods

PubMed, EMBASE and Web of Science were electronically searched for relevant studies comparing endoscopic resection and gastrectomy for EGC from 1976 through March 2015. The primary endpoints were en bloc resection and histologically complete resection rates. The secondary endpoints were duration of hospital stay and rates of complications, recurrence, metachronous cancer and overall survival.

Results

This meta-analysis enrolled 10 studies with 2070 patients: 993 patients who underwent endoscopic resection and 1077 who underwent gastrectomy. Endoscopic resection was associated with shorter hospital stay (standardized mean difference ?2.02; 95 % confidence interval [CI] ?2.64 to ?1.39) and lower complication rate (relative risk [RR] 0.41; 95 % CI 0.22–0.76) than gastrectomy. However, endoscopic resection was associated with lower rates of en bloc resection (odds ratio [OR] 0.05; 95 % CI 0.02–0.16) and histologically complete resection (OR 0.04; 95 % CI 0.01–0.11) and higher rates of recurrence (RR 5.23; 95 % CI 2.43–11.27) and metachronous cancer (RR 5.22; 95 % CI 2.40–11.34) than gastrectomy. Overall survival rate (OR 1.18; 95 % CI 0.76–1.82) was similar.

Conclusions

Endoscopic resection is minimally invasive and as effective as surgery, suggesting that the former be considered standard treatment for EGC. It should be recommended as standard treatment for EGC with indications. Additional randomized controlled trials from more countries are required.

     

Predictors of Increased Length of Hospital Stay Following Laparoscopic Sleeve Gastrectomy from the National Surgical Quality Improvement Program

Background

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure in the USA. Identifying preoperative risk factors for prolonged postoperative hospital stay will help appropriately select patients for fast-track protocols and avoid costly readmissions. To date, there has been no large national database analysis of risk factors for prolonged length of stay following laparoscopic sleeve gastrectomy.

Methods

Laparoscopic sleeve gastrectomy procedures reported to the American College of Surgeons National Surgical Quality Improvement Program between 2009 and 2012 were reviewed. Open procedures and revisional procedures were excluded. Baseline patient characteristics and preoperative lab values were reviewed. Univariate analysis was conducted to identify patient factors that predicted prolonged hospitalization (defined as ≥?3 days). Multivariate logistic regression was used to identify factor associated with prolonged length of stay.

Results

We identified 11,430 patients who underwent laparoscopic sleeve gastrectomy. The median length of stay was 2 days and 18.4% required hospitalization ≥?3 days. Multivariate analysis revealed that female sex, age greater than 65, body mass index greater than 50, chronic obstructive pulmonary disease, hypertension, renal insufficiency, anemia, and prolonged operative time were significantly associated with prolonged hospital stay.

Conclusions

Preoperative patient characteristics as well as operative details predict prolonged length of stay following laparoscopic sleeve gastrectomy. As the utilization of fast-track protocols in bariatric surgery programs expands, these data may be used to assist in the selection of patients who may be inappropriate for rapid discharge from the hospital after sleeve gastrectomy as well as guide medical optimization strategies preoperatively.

     

Converting a Sleeve Gastrectomy to a Gastric Bypass for Weight Loss Failure—Is It Worth It?

Background

Sleeve gastrectomy (SG) is gaining popularity and has become the procedure of choice for many bariatric surgeons. Long-term weight loss failure is not uncommon. The preferred revisional procedure for these patients is still under debate.

Objective

The objective of this study was to assess the safety and efficacy of laparoscopic gastric bypass as a revisional surgery for sleeve gastrectomy patients with weight loss failure.

Setting

The study was done at a bariatric surgery center in a university hospital.

Methods

We reviewed our prospectively collected database and identified all patients who underwent conversion of a sleeve gastrectomy to a gastric bypass for weight loss failure. Data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved.

Results

Twenty-three patients with a mean body mass index (BMI) of 41.6 kg/m2 (range 34.1–50.1 kg/m2) underwent conversion to a gastric bypass. Four patients underwent a gastric band prior to the sleeve gastrectomy, and two patients underwent a re-sleeve gastrectomy prior to conversion to a gastric bypass.At a mean follow-up of 24 months (range 9–46 months), the average body mass index (BMI) decreased to 33.8 kg/m2 and the excess body mass index loss (EBMIL) was 42.6%. Diabetes, hypertension, dyslipidemia, and obstructive sleep apnea resolved or improved in 44.4, 45.5, 50, and 50% of the patients, respectively. Three patients developed early postop complications (13%), while late complications occurred in four patients (17%).

Conclusion

Converting a sleeve gastrectomy to a gastric bypass for weight loss failure is safe, yet weight loss benefit is limited.

     

Sleeve Gastrectomy Reversed Obesity-Induced Hypogonadism in a Rat Model by Regulating Inflammatory Responses in the Hypothalamus and Testis

Background

Obesity is a metabolic disease with a serious health burden in children and adults, and it induces a variety of conditions including subfecundity. Sleeve gastrectomy showed encouraging results in terms of weight loss and improve quality of life, and this study aimed to determine whether sleeve gastrectomy could reverse obesity-induced impaired fertility in male Sprague–Dawley rats.

Methods

After 16 weeks of a chow diet (CD) or a high-fat diet (HFD) challenge, rats on the HFD were given a sleeve gastrectomy or sham operation and then fed an HFD for another 8 weeks. Serum glucose, insulin, lipids, sex hormone, sperm quality, inflammatory profile of the testis, and hypothalamic Kiss1 expression in the three study groups were compared.

Results

Sleeve gastrectomy significantly decreased HFD-induced obesity and serum glucose and insulin levels. It also reversed the HFD-induced increase in teratozoospermia and decreases in sperm motility and progressive motility. Testicular morphological abnormalities were also improved after sleeve gastrectomy. Enzyme-linked immunosorbent assay showed that the expression of sex hormones increased after sleeve gastrectomy and that expression of inflammatory factors decreased. The HFD induced a hypothalamic inflammatory response that inhibited Kiss1 expression, which in turn mediated sex hormone expression. Sleeve gastrectomy treatment improved the hypothalamic response.

Conclusions

The results consistently showed that sleeve gastrectomy reversed obesity-induced male fertility impairment by decreasing the inflammatory responses of the testis and hypothalamus.

     

Impact of synthetic ghrelin administration for patients with severe body weight reduction more than 1 year after gastrectomy: a phase II clinical trial

Purpose

Ghrelin is mainly secreted from the stomach and plays a role in appetite, weight gain, and the promotion of a positive energy balance. The levels of ghrelin decrease immediately after gastrectomy. We herein investigated the effect of the administration of synthetic ghrelin to treat postoperative severe weight loss in a prospective, one-arm clinical trial to develop new strategies for weight gain.

Methods

Ten patients (four distal gastrectomy and six total gastrectomy) received ghrelin treatment. Eligibility criteria included patients who underwent gastrectomy more than 1 year previously and 15 % body weight loss from the preoperative weight or a body mass index under 19. Synthetic human ghrelin (3 μg/kg) was administered to the patients twice a day for 1 week. Oral intake of calories, appetite [evaluated using the visual analog scale (VAS)], and body weight before and during administration of ghrelin were compared.

Results

There was a significant difference in the oral food intake before and during treatment (before treatment: 1236 ± 409 kcal vs. during treatment: 1398 ± 365 kcal, p = 0.039), and the VAS for appetite significantly improved with each day of ghrelin administration (p < 0.05). Significant amounts of body weight were gained (39.5 ± 6.8 vs. 40.1 ± 6.9, p = 0.037).

Conclusions

The administration of synthetic ghrelin improved the food intake and was effective for treating appetite loss and body weight loss. Synthetic ghrelin may be a promising new therapy for severe body weight loss following gastrectomy.

     

Body composition changes after totally laparoscopic distal gastrectomy with delta-shaped anastomosis: a comparison with conventional Billroth I anastomosis

Background

The purpose of this study was to compare body composition changes of patients undergoing totally laparoscopic distal gastrectomy (TLDG) with delta-shaped anastomosis (DSA) versus conventional laparoscopic distal gastrectomy (CLDG).

Methods

Data from gastric cancer patients who underwent laparoscopic distal gastrectomy for histologically proven gastric cancer in KNUMC from January 2013 to May 2014 were collected and reviewed. We examined 85 consecutive patients undergoing TLDG or CLDG: 41 patients underwent TLDG and 44 patients underwent CLDG. Body composition was assessed by segmental multifrequency bioelectrical impedance analysis. We compared the changes in nutritional parameters and body composition from preoperative status between the two groups at postoperative 6 and 12 months.

Results

All of the postoperative changes in the body composition and nutritional indices were similar between the two groups with the exception of visceral fat areas (VFAs) and albumin levels. VFAs increased at 6 months postoperatively in the TLDG group and a significant difference was shown at 12 months postoperatively between the TLDG and CLDG groups (86.7 ± 22.8 and 74.7 ± 21.9 cm², respectively, P < 0.05). Postoperative albumin levels were higher in the TLDG group with statistical significance at 6 and 12 months after surgery (6 months, P = 0.028; 12 months, P = 0.012).

Conclusions

The influence of TLDG with DSA on nutrition and body composition seemed comparable to those of CLDG. Six months postoperatively, VFAs and albumin levels were recovered in the TLDG group but not in the CLDG group. Thus, TLDG seems to be a novel surgical method.

     

Medium-Term Results of Combined Laparoscopic Sleeve Gastrectomy and Modified Jejuno-Ileal Bypass in Bariatric Surgery

Background

The ideal bariatric operation achieves 70–100 % maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options.

Methods

A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75 cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75 cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013.

Results

One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43 years (IQR 37–47), and median preoperative body mass index (kg/m²) was 52 (IQR 49–59). All operations were completed laparoscopically. Excess weight loss was 78 % (IQR 70–83 %, 12 months, n?=?168), 79 % (IQR 70–85 %, 24 months), maintained at most recent follow-up with 77 % (IQR 68–84 %, n?=?168), and for 8 year follow-up alone 75 % (IQR 66–84 %, n?=?18). There was no operative mortality and 5.4 % morbidity. A 6.5 % of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8 %) and zinc deficiency (25.6 %) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3 % and improved in the remainder of patients, hypertension resolved in 92.3 % and improved in the rest.

Conclusions

Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.

     

Laparoscopic right colectomy in patients treated with previous gastrectomy

Purpose

Laparoscopic colorectal surgery is increasingly being performed in patients treated with previous abdominal surgery. This is a retrospective study designed to evaluate the feasibility of laparoscopic right colectomy in patients with a previous history of gastrectomy.

Methods

Of 838 consecutive patients who underwent elective laparoscopic right colectomy, 23 had previously undergone gastrectomy (PG group) and 516 had no history of previous abdominal surgery (NS group). The short-term surgical outcomes were retrospectively investigated in the PG and NS groups.

Results

The median patient age was 75 years in the PG group and 67 years in the NS group (p = 0.0026), and the median body mass index in both groups was 19.2 and 22.6 kg/m², respectively (p = 0.0006). The mean operative time, amount of blood loss and postoperative hospital stay were similar. One patient in the PG group and five patients in the NS group required conversion to laparotomy (p = 0.1307). Three patients in the PG group experienced postoperative complications, one each with an intraperitoneal abscess, wound infection and enterocolitis; however, none of these complications were directly attributable to adhesiolysis. The rates of intraoperative and postoperative complications were similar.

Conclusions

Laparoscopic right colectomy is feasible in patients treated with previous gastrectomy.

     

Evaluation of the Safety and Feasibility of Laparoscopic Total Gastrectomy in Clinical Stage I Gastric Cancer Patients

Background

This retrospective study was designed to assess the feasibility of laparoscopic total gastrectomy (LTG) in clinical stage I gastric cancer patients, and validate the appropriateness of the widespread adoption of LTG for experienced open surgeons.

Methods

Eighty-eight patients with clinical stage I gastric cancer underwent LTG in our hospitals (n = 55) and affiliated hospitals (n = 33). Esophagojejunostomy was performed intracoporeally using a circular stapler with an incision in the left upper abdomen. We investigated the patients’ clinicopathologic factor, and evaluated the effect of hospital volume on short-term outcomes.

Results

Fixed insertion of the anvil head was successfully achieved in all patients (lift-up method in 58 patients and transoral method in 28 patients), although 2 patients were converted to open surgery. The approach using a circular stapler through a small incision from the upper left quadrant of the abdomen facilitated a good laparoscopic visual field for the plane of the esophagojejunostomy. Fourteen patients developed Clavien–Dindo classification grade II or more postoperative complications, and the overall operative morbidity rate was 15.9 %. No anastomotic leakage was encountered in this series. No significant difference was observed in clinical outcomes between patients in the high- and low-volume hospital groups.

Conclusions

Laparoscopic total gastrectomy can be performed safely on clinical stage I gastric cancer patients by surgeons with sufficient experience in open gastrectomy and therefore represents a feasible procedure that is not clinically impacted by hospital volume.

     

Results of a nationwide questionnaire-based survey on nutrition management following gastric cancer resection in Japan

Purpose

A study was conducted to clarify the actual status of nutrition management after gastric cancer surgery in Japan and obtain basic data for optimizing perioperative nutrition management.

Methods

A questionnaire was sent to 354 hospitals with at least 50 cases of gastric cancer surgery per year. Questions included the perioperative nutrition management and length of hospital stay for patients who underwent gastric cancer surgery within three months of the survey.

Results

Responses were obtained from 242 hospitals (68%; 20,858 patients). Nutrition management was consistent between laparotomy and laparoscopic surgery for 84% of respondents. The number of postoperative days was the most commonly chosen index for starting oral feeding. The most commonly chosen index for hospital dischargeability was diet composition/amount consumed in 182 hospitals (44%), followed by laboratory data stabilization in 106 hospitals (26%), and the number of postoperative days in 87 hospitals (21%). A positive correlation was found between the mean length of postoperative hospital stay and starting oral feeding (r = 0.23 for distal gastrectomy; r = 0.34 for total gastrectomy). The length of hospital stay tended to be shorter with an earlier start of oral feeding (p < 0.01).

Conclusion

Early postoperative oral feeding may be a factor in reducing the length of hospital stay after gastric cancer surgery.

     

The Oncological Value of Omentectomy in Gastrectomy for Cancer

Aim

The aim of this study was to determine the oncologic value of omentectomy in patients undergoing gastrectomy for gastric cancer.

Methods

All consecutive patients with gastric cancer that underwent gastrectomy with curative intent between April 2012 and August 2015 were prospectively analyzed. The greater omentum was separately marked during operation and pathologically evaluated for the presence of omental lymph nodes and tumor deposits.

Results

In total, 50 patients were included. The greater omentum harbored lymph nodes in nine (18 %) patients. The omental lymph nodes contained metastases in one (2 %) patient, still free of disease after 20 months. Omental tumor deposits were found in four (8 %) patients; one died <30 days postoperative and three developed peritoneal carcinomatosa after 4, 4, and 8 months. Patients with omental tumor deposits had a significantly reduced 1-year disease-free survival compared to patients without tumor deposits (0 vs. 58.7 %, p?=?0.003). No predictive factors for omental tumor involvement could be identified.

Conclusion

Omental lymph node metastases or tumor deposits are present in 10 % of Western European patients undergoing gastrectomy for gastric cancer. Omentectomy has a prognostic and oncologic value in the curative treatment of patients with gastric cancer. As no predictive factors for omental tumor involvement could be identified, omentectomy should be the standard in gastrectomy for gastric cancer patients.