Modified stapling technique of esophagojejunal anastomosis

The most dangerous complication of total gastrectomy, often causing postoperative death, is dehiscence of esophagojejunal anastomosis. After analyzing more then 300 patients undergoing surgery for gastric and/or cardiac carcinoma at our department in the period 1992-96, we concluded that the main cause of anastomotic dehiscence was a technically insufficient anastomosis, and the main risk factor was hypertrophied muscular layer of the esophagus (predominantly in advanced cardiac carcinoma). In this paper we discuss indications for, and the surgical technique of, our own modification of mechanical esophagojejunal anastomosis. In the period between 1 January 1997 and 1 March 2001, 148 procedures were performed using the modified anastomotic technique. In only two patients (1.35%) were radiological signs of small anastomotic leakage observed. The described modification of mechanical esophagojejunal anastomosis is safe and is not a time-consuming procedure. It is highly recommended in the treatment of the obstructive cardiac carcinoma with a compensatory hypertrophied muscular layer of the esophagus.     

Ataxic gait following total gastrectomy for gastric cancer

A 58-year-old woman, who had undergone total gastrectomy for early gastric cancer 9 years previously, visited the outpatient clinic complaining of progressive difficulty in walking for 15 d. Laboratory examinations showed macrocytic anemia and a decreased serum vitamin B12 concentration and increased serum concentrations of folate, vitamin E and copper. Magnetic resonance imaging showed multifocal high signal intensities along the posterior column of the cervical and thoracic spinal cord. Treatment consisted of intramuscular injections of vitamin B12 for 7 d, which increased her serum level of vitamin B12 to normal. This was followed by weekly intramuscular injections of vitamin B12 for another 2 wk and oral administration of vitamin B12 three times per day. After comprehensive rehabilitation for 4 wk, she showed sufficient improvements in strength and ataxic gait, enabling her to return to her normal daily activities.     

Proximal gastrectomy with jejunal interposition and TGRY anastomosis for proximal gastric cancer

AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).METHODS: From January 2009 to January 2011, thirty-five patients underwent PGJI, and forty-one patients underwent TGRY. The surgical efficacy and short-term follow-up outcomes were compared between the two groups.RESULTS: There were no differences in the demographic and clinicopathological characteristics. The mean operation duration and postoperative hospital stay in the PGJI group were statistically longer than those in the TGRY group (P = 0.00). No anastomosis leakage was observed in two groups. No statistically significant difference was found in endoscopic findings, Visick grade or serum albumin level. The single-meal food intake in the PGJI group was more than that in the TGRY group (P = 0.00). The PG group showed significantly better hemoglobin levels in the second year (P = 0.02). The two-year survival rate was not significantly different (PGJI vs TGRY, 93.55% vs 92.5%, P = 1.0).CONCLUSION: PGJI is a safe, radical surgical method for proximal gastric cancer and leads to better outcomes in terms of the single-meal food intake and hemoglobin level, compared with TGRY in the short term.     

Helicobacter pylori infection following partial gastrectomy for gastric cancer

Gastric remnants are an inevitable consequence of partial gastrectomy following resection for gastric cancer.The presence of gastric stumps is itself a risk factor for redevelopment of gastric cancer.Helicobacter pylori(H.pylori)infection is also a well-known characteristic of gastric carcinogenesis.H.pylori colonization in the remnant stomach therefore draws special interest from clinicians in terms of stomach cancer development and pathogenesis;however,the H.pylori-infected gastric remnant is quite different from the intact organ in several aspects and researchers have expressed conflicting opinions with respect to its role in pathogenesis.For instance,H.pylori infection of the gastric stump produced controversial results in several recent studies.The prevalence of H.pylori infection in the gastric stump has varied among recent reports.Gastritis developing in the remnant stomach presents with a unique pattern of inflammation that is different from the pattern seen in ordinary gastritis of the intact organ.Bilerefluxate also has a significant influence on the colonization of the stomach stump,with several studies reporting mixed results as well.In contrast,the elimination of H.pylori from the gastric stump has shown a dramatic impact on eradication rate.H.pylori elimination is recognized to be important for cancer prevention and considerable agreement of opinion is seen among researchers.To overcome the current discrepancies in the literature regarding the role of H.pylori in the gastric stump,further research is required.     

Early gastric stump cancer following distal gastrectomy

Background—Gastric stump cancer(GSC) is usually diagnosed at an advanced stage, and consequently theprognosis is poor.
Aims—To investigate theclinicopathological characteristics of GSC at an early stage to assistin its identification, and thereby improve its prognosis.
Methods—Forty three patients withresected early GSC were compared with 156 patients with resectedprimary early cancer in the upper third of the stomach.
Results—Sixty five per cent (28/43)of the early GSC patients showed the elevated type endoscopically,although the frequency of the depressed type in GSC has tended toincrease in the past five years. This occurred in less than 26%(40/156) of the primary early cancers. Half of the early GSCs werelocated on the lesser curvature (47%), and revealed differentiatedadenocarcinoma (81%) histologically. The male:female ratio of earlyGSC cases was about 6:1, which was much higher than that in patientswith primary early cancer. The five year survival rates of patientswith early GSCs and early primary cancers were 84% and 95%,respectively. GSC had a favourable prognosis, if it was detected at anearly stage.
Conclusion—To detect early GSC, ourresults suggest that special attention should be given to elevated aswell as depressed lesions on the lesser curvature of the stomach,particularly in men, during endoscopic examinations.

Keywords:gastric stump cancer; early gastric cancer; prognosis; endoscopy

     

Remnant-stump gastric cancer following partial gastrectomy.

Between 1970 and 1990, a total of 2,189 patients with gastric cancer underwent resection in the First Department of Surgery, Kurume University Hospital. Of these, 54 patients had previously undergone a partial gastrectomy. The time interval between the initial partial gastrectomy and the resection of the remnant-stump gastric cancer was more than 10 years in 25 patients and less than 10 years in 29 patients. Those with a time interval of more than 10 years we have termed remnant-stump cancer. The original pathology was a gastric ulcer in 13, a duodenal ulcer in 5, a gastric polyp in 1, and a gastric cancer in 6 patients. Of the 19 patients that had undergone an initial operation for benign disease (Group 1), 15 (79%) patients had received initial reconstruction by B-II and 4 (21%) by B-I. On the other hand, of the 6 patients with an initial operation for gastric cancer (Group 2), 3 (50%) had undergone reconstruction by B-I and the other 3 (50%) had received a B-II procedure. Twenty-three of 25 (92%) remnant-stump gastric cancers underwent total gastrectomy, while the other 2 (8%) were early remnant-stump cancers in the stoma and underwent partial gastrectomy. In group 1, only 5 out of 19 (26.3%) patients are alive, while in group 2 all 6 patients are alive, including the 2 (33.3%) early-stage cancers that were found through periodical endoscopic follow-up examinations.     

Case-matched comparison of laparoscopy-assisted and open distal gastrectomy for gastric cancer

AIM: To compare shortand long-term outcomes of laparoscopy-assisted and open distal gastrectomy for gastric cancer. METHODS: A retrospective study was performed by comparing the outcomes of 54 patients who underwent laparoscopy-assisted distal gastrectomy (LADG) with those of 54 patients who underwent open distal gastrectomy (ODG) between October 2004 and October 2007. The patients’ demographic data (age and gender), date of surgery, extent of lymphadenectomy, and differentiation and tumor-node-metastasis stage of the tumor were examined. The operative time, intraoperative blood loss, postoperative recovery, complications, pathological findings, and follow-up data were compared between the two groups.RESULTS: The mean operative time was significantly longer in the LADG group than in the ODG group (259.3 ± 46.2 min vs 199.8 ± 40.85 min; P < 0.05), whereas intraoperative blood loss and postoperative complications were significantly lower (160.2 ± 85.9 mL vs 257.8 ± 151.0 mL; 13.0% vs 24.1%, respectively, P < 0.05). In addition, the time to first flatus, time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (3.9 ± 1.4 d vs 4.4 ± 1.5 d; 4.6 ± 1.2 d vs 5.6 ± 2.1 d; and 9.5 ± 2.7 d vs 11.1 ± 4.1 d, respectively; P < 0.05). There was no significant difference between the LADG group and ODG group with regard to the number of harvested lymph nodes. The median followup was 60 mo (range, 5-97 mo). The 1-, 3-, and 5-year disease-free survival rates were 94.3%, 90.2%, and 76.7%, respectively, in the LADG group and 89.5%, 84.7%, and 82.3%, respectively, in the ODG group. The 1-, 3-, and 5-year overall survival rates were 98.0%, 91.9%, and 81.1%, respectively, in the LADG group and 91.5%, 86.9%, and 82.1%, respectively, in the ODG group. There was no significant difference between the two groups with regard to the survival rate. CONCLUSION: LADG is suitable and minimally invasive for treating distal gastric cancer and can achieve si     

Triangulating stapling technique: An alternative approach to colorectal anastomosis

The triangulating stapling technique was employed to perform colorectal anastomosis in 259 patients. In 220 patients, the anastomosis was performed between the colon and nonperitonealized rectum. This anastomotic technique is safe and reliable and is an effective alternative to a circular stapling device, with minimal morbidity. The incidence of leak rate is comparable to anastomoses created by a circular stapling device. The main advantage seems to be the very low incidence of anastomotic stenosis.     

Esophageal manometric changes and gastroesophageal reflux symptoms after distal gastrectomy for gastric cancer

BACKGROUND/AIMS: Gastroesophageal reflux is known to be a common complication after gastrectomy. However, its mechanism is not completely understood. We investigated the effects of distal gastrectomy for gastric cancer on the lower esophageal sphincter (LES) and esophageal motility. METHODOLOGY: In 18 patients who underwent distal gastrectomy reconstructed with Billroth I method for gastric cancer, esophageal motility and LES function were evaluated by means of a low-compliance manometric system. The LES pressure was determined by a rapid pull-through technique. Endoscopy before and after operation determined presence or absence of esophagitis and hiatus hernia. RESULTS: No significant differences were observed in esophageal contractile amplitudes before and after distal gastrectomy. After distal gastrectomy, five patients had reflux symptoms of heartburn and regurgitation; 11 had none. Endoscopy revealed esophagitis after distal gastrectomy in two patients with reflux symptoms and one patient without reflux symptoms. The LES pressure in patients with reflux symptoms decreased significantly after distal gastrectomy (before gastrectomy: 26.1 +/- 1.1 mmHg, after distal gastrectomy: 15.3 +/- 3.5 mmHg, p<0.05). There was no significant change in patients without reflux symptoms. CONCLUSIONS: This study demonstrated that LES pressure after distal gastrectomy in patients with reflux symptoms was significantly lower than that before gastrectomy. This result suggested that LES pressure decrease plays an important role in development of gastroesophageal reflux after distal gastrectomy reconstruction with the Billroth I method.     

Postoperative complications following gastrectomy for gastric cancer during the last decade

BACKGROUND/AIMS: The reduction in the incidence of severe postoperative complications has resulted in a significant increase in the survival of patients with gastric cancer. METHODOLOGY: A total of 879 patients undergoing gastrectomy for gastric cancer during the last decade were retrospectively evaluated for postoperative complications, mortality and associated risk factors. RESULTS: The most frequent complications were anastomotic leakage (3.0%) and wound infection (2.8%) followed by the development of pancreatic fistulae (2.2%) and intra-abdominal abscesses (1.5%). Multiple logistic regression analysis identified various independent risk factors including the extent of lymph node dissection (D1D2 vs. D3) for anastomotic leakage (RR 3.6, P<0.05), splenectomy or distal pancreatosplenectomy for pancreatic fistulae (RR 27.4, P<0.0001) and operative time (360 min < or =) for intra-abdominal abscess (RR 4.8, P<0.05). In total, fourteen patients (1.6%, n=879) died from postoperative complications, with 5 patients dying following non-curative gastrectomy (5.6%, n=90). The complications most associated with death were anastomotic leakage (4 patients) and pneumonia (2 patients). CONCLUSIONS: In view of the potential risk of complications, we should carefully evaluate the indications for aggressive lymph node dissection and/or combined resection of neighboring organs as well as non-curative gastrectomy.     

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.     

Palliative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS: Although palliative gastrectomy for advanced gastric cancer may be favorable in selected patients presenting with bleeding and obstruction, little has been reported about the clinical significance of palliative gastrectomy, including prognosis. METHODOLOGY: A retrospective comparison between 84 patients with palliative gastrectomy (PG group) and 100 patients with unresectable operation (UO group) for advanced gastric cancer was carried out. RESULTS: The incidence of serosal invasion, peritoneal dissemination, hepatic and lymph node metastases, and undifferentiated tissue type in the UO group were significantly higher than in the PG group. Median survival after operation in the PG group (20.6 months) was significantly longer than in the UO group (5.7 months). Also, in stage IVb patients, median survival time in the PG group (10.2 months) was significantly longer than in the UO group (5.0 months). However, median survival in the patients with synchronous liver metastasis between PG (8.4 months) and UO (4.6 months) groups was not significantly different. Survival rates after operation of 6 months, 1 year and 2 years in all patients between the palliative gastrectomy group versus UO group were 83.6% versus 38.3% (P < 0.01), 63.0% versus 9.3% (P < 0.01) and 35.2% versus 0% (P < 0.01), respectively. CONCLUSIONS: Palliative gastrectomy compared to unresectable operation may be effective for improvement of prognosis even if stage IVb patients with peritoneal dissemination and/or distant lymph node metastasis. However, it may be unfavorable on survival of patients with synchronous liver metastasis.     

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase Ⅲ evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robotassisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase Ⅲ trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric cancer.     

Ileocolonic anastomosis after right hemicolectomy for carcinoma: stapled or hand-sewn?

440 patients were prospectively enrolled in a randomized, multicenter trial to compare 4 types of manual (84 interrupted end-to-end, 77 continuous end-to-side) 82 interrupted end-to-side, and 91 continuous end-to-side (polyglycolic derived suture) and 1 type of stapled (106 side-to-side with GIA + TA devices) ileocolonic anastomosis after right hemicolectomy for carcinoma. The trial was designed according to Schwartz' pragmatic formulation. All 5 groups were well-matched, except for a lower rate of intraoperative sepsis in the stapled group (P<0.02). The main end point was anastomotic leakage detected clinically or by routine sodium diatrizoate enema on the 8–10th postoperative day. Results showed that stapled ileocolonic anastomosis was associated with less anastomotic leakages (2.8%) than all the other techniques combined (8.3%). In spite of the fact that staples are approximately ten times more expensive, our results suggest performing side-to-side (GIA + TA) mechanical anastomosis after right resection for carcinoma.

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Résumé 440 malades ont été inclus prospectivement dans un essai multi-centrique randomisé afin de comparer 4 types de sutures manuelles avec un fil lentement résorbable (84 sutures termino-terminales à points séparés, 77 termino-terminales par sujet, 82 latéro-terminales à points séparés et 91 termino-latérales par sujet) et une variété d'anastomoses mécaniques (106 sutures latéro-latérales aux pinces GIA + TA). Il s'agissait d'anastomoses iléo-coliques après hémicolectomie droite pour cancer. L'essai a été réalisé selon la formulation pragmatique de Schwartz. Tous les 5 groupes étaient bien appareillés à l'exception du plus petit taux de suppuration dans le groupe par anastomose mécanique (P<0.02). Le principal résultat était le lachâge d'anastomose détecté cliniquement ou par un lavement de routine aux produits hydrosolubles au 8–10ème jour post-opératoire. Les résultats montraient que les anastomoses mécaniques étaient associées avec moins de lachage d'anastomose (2,8%) que toutes les autres techniques (8,3%). En dépit du fait que les anastomoses mécaniques sont approximativement 10 fois plus chères, nos résultats suggèrent qu'il faut réaliser des anastomoses latéro-larérales (GIA + TA) mécaniques après hémi-colectomie droite pour cancer.

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The following surgeons participated in this study: F. Benhamida (Sens), J.-L. Bernard (Orléans), P. Breil (Clichy), J. Chipponi (Clermont-Ferrand), J.-C. Cour (Tours), F. Dazza (Paris), J.-P. Delalande (Pithiviers), B. Descottes (Limoges), G. Desvignes (Montargis), C. Devien (Saint-Cloud), E. Dewulf (Brussels), A. El Hadad, D. Brassier (Aulnay-sous-Bois), P.-L. Fagniez, M. Kracht, N. Rotman, C. Thomsen (Créteil), A. Fingerhut, P. Oberlin, J. Pourcher (Poissy), J. Francin (Quimperlé), J.-M. Hay, Y. Flamant, F. Lacaine, G. Zeitoun (Colombes), H. Hennet (Romorantin), G. Kohlmann (Corbeil), R. Kaswin (Le Mans), A. Konrat (Compiègne), B. Lagadec (Paris), P. Laigneau (Meaux), X. Pouliquen, B. Vacher (Argenteuil), F. Poulton (St-Brieuc), J. Renaud (Longjumeau), M. Rodary (Orsay), F. Rouffet (Juvisy), M. Sage (Auxerre), J.-L. Sicard (Nice), M. Timmermans (Ottignies)     

Clinicopathologic features of remnant gastric cancer over time following distal gastrectomy

AIM: To investigate remnant gastric cancer(RGC) at various times after gastrectomy, and lay a foundation for the management of RGC.METHODS: Sixty-five patients with RGC 2 years and 10 years after gastrectomy(RGC Ⅰ) and forty-nine with RGC 10 years after gastrectomy(RGC Ⅱ) who underwent curative surgery were enrolled in the study.The clinicopathologic factors, surgical outcomes, and prognosis were compared between RGC Ⅰ and RGC Ⅱ.RESULTS: There was no significant difference in surgical outcomes between RGC Ⅰ and RGC Ⅱ. For patients reconstructed with Billroth Ⅱ, significantly more patients were RGC Ⅱ compared with RGC(71.9%vs 21.2%, P 0.001), and more RGC Ⅱ patients had anastomotic site locations compared to RGC Ⅰ(31.0%vs 56.3%, P = 0.038). The five-year survival rates for the patients with RGC Ⅰ and RGC Ⅱ were 37.6%and 47.9%, respectively, but no significant difference was observed. Borrmann type and tumor stage were confirmed to be independent prognostic factors in both groups.CONCLUSION: RGC Ⅱ is located on the anastomotic site in higher frequency and more cases develop after Billroth Ⅱ reconstruction than RGC Ⅰ.     

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

R a d i c a l g a s t r e c t o m y w i t h a n a d e q u a t e l y m p h-adenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer(GC). A number of randomized controlled trials and meta-analysis provide phase Ⅲ evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomyfor cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.     

Risk factors to predict severe postoperative pancreatic fistula following gastrectomy for gastric cancer

AIM:To allow the identification of high-risk postoperative pancreatic fistula(POPF)patients with special reference to the International Study Group on Pancreatic Fistula(ISGPF)classification.METHODS:Between 1997 and 2010,1341 consecutive patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery,Kyoto Prefectural University of Medicine,Japan.Based on the preoperative diagnosis,total or distal gastrectomy and sufficient lymphadenectomy was performed,mainly according to the Japanese guidelines for the treatment of gastric cancer.Of these,35 patients(2.6%)were diagnosed with Grade B or C POPF according to the ISGPF classification and were treated intensively.The hospital records of these patients were reviewed retrospectively.RESULTS:Of 35 patients with severe POPF,17(49%)and 18(51%)patients were classified as Grade B and C POPF,respectively.From several clinical factors,the severity of POPF according to the ISGPF classification was significantly correlated with the duration of intensive POPF treatments(P=0.035).Regarding the clinical factors to distinguish extremely severe POPF,older patients(P=0.035,65 years≤vs<65 years old)and those with lower lymphocyte counts at the diagnosis of POPF(P=0.007,<1400/mm3vs 1400/mm3≤)were significantly correlated with Grade C POPF,and a low lymphocyte count was an independent risk factor by multivariate analysis[P=0.045,OR=10.45(95%CI:1.050-104.1)].CONCLUSION:Caution and intensive care are required for older POPF patients and those with lower lymphocyte counts at the diagnosis of POPF.