Outcome after gastrectomy in gastric cancer patients with type 2 diabetes

AIM: To evaluate the prognosis of type II diabetes mellitus (T2DM) after gastrectomy and related factors in gastric cancer patients.METHODS: 403 gastric cancer patients with T2DM were studied, who underwent gastrectomy between May 2003 and September 2009. A review of medical records and telephone interviews was performed in this cross-sectional study. The factors included in the statistical analysis were as follows: gender, age, type of surgery, preoperative body mass index (BMI), current BMI, BMI reduction ratio, preoperative insulin or oral diabetic medicine requirement, follow-up duration, and current state of diabetes. Assessment of diabetes status after surgery was classified into four categories according to the change in hypoglycemic agents after surgery and present status of T2DM: resolution, improvement, same, and worse.RESULTS: The mean follow-up duration was 33.7 mo (± 20.6 mo), preoperative BMI was 24.7 kg/m² (± 3.0 kg/m²), and BMI reduction ratio was 9.8% (± 8.6%). After surgery, T2DM was cured in 58 patients (15.1%) and was improved in 117 patients (30.4%). According to the type of surgery, the BMI reduction ratio was significantly higher in the total gastrectomy and Roux-en-Y reconstruction group [14.2% ± 9.2% vs 9.2% ± 7.7% (Billroth II group), P < 0.001] and significantly lower in the subtotal gastrectomy and Billroth I reconstruction group [7.6% ± 8.0%, 9.2% ± 7.7% (Billroth II group), P < 0.001]. The BMI reduction ratio, follow-up duration after surgery, type of surgery, extent of gastrectomy, and performance of duodenal bypass were significantly correlated to the course of T2DM (P < 0.05). The BMI reduction ratio was the most influential factor on T2DM status. In a subgroup analysis of patients with a BMI reduction ratio of 10% or less (n = 206), T2DM was cured in 15 (7.6%) patients and was improved in 57 (28.8%) patients after surgery, and only the duration of surgery was significantly correlated to T2DM status (P = 0.022).CONCLUSION: The course of T2DM was significantly correlated to the BMI reduction ratio but not to the type of surgery without a significant change in BMI.     

'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract

BACKGROUND:

Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a ‘short’ DBE in patients with surgically altered anatomy.

METHODS:

A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a ‘short’ DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed.

RESULTS:

A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple’s operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications.

CONCLUSION:

DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard ‘long’ DBEs have limitations of long working length and the need for modified ERCP accessories. ‘Short’ DBEs are equally as effective in reaching the target limb as standard ‘long’ DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.     

Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy

AIM: To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery.METHODS: Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth II (BII) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression.RESULTS: Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semi-liquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BII reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BIIgroup vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BII group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BII group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001).CONCLUSION: This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.     

Eradication rate and histological changes after Helicobacter pylori eradication treatment in gastric cancer patients following subtotal gastrectomy

AIM: To investigate the eradication rate and histological changes after Helicobacter pylori(H. pylori) eradication treatment following subtotal gastrectomy for gastric cancer.METHODS: A total of 610 patients with H. pylori infection who had undergone surgery for either early or advanced gastric adenocarcinoma between May 2004 and December 2010 were retrospectively studied. A total of 584 patients with proven H. pylori infection after surgery for gastric cancer were enrolled in this study. Patients received a seven day standard triple regimen as first-line therapy and a 10 d bismuthcontaining quadruple regimen as second-line therapy in cases of eradication failure. The patients underwent an esophagogastroduodenoscopy(EGD) between six and 12 mo after surgery, followed by annual EGDs. A further EGD was conducted 12 mo after confirming the result of the eradication and the histological changes. A gastric biopsy specimen for histological examination and Campylobacter-like organism testing was obtained from the lesser and greater curvature of the corpus of the remnant stomach. Histological changes in the gastric mucosa were assessed using the updated Sydney system before eradication therapy and at follow-up after 12 mo.RESULTS: Eradication rates with the first-line and second-line therapies were 78.4%(458/584) and 90%(36/40), respectively, by intention-to-treat analysis and 85.3%(458/530) and 92.3%(36/39), respectively, by per-protocol analysis. The univariate and multivariate analyses revealed that Billroth Ⅱ surgery was an independent factor predictive of eradication success in the eradication success group(OR = 1.53, 95%CI: 1.41-1.65, P = 0.021). The atrophy and intestinal metaplasia(IM) scores 12 mo after eradication were significantly lower in the eradication success group than in the eradication failure group(0.25 ± 0.04 vs 0.47 ± 0.12, P = 0.023; 0.27 ± 0.04 vs 0.51 ± 0.12, P = 0.015, respectively). The atrophy and IM scores 12 mo after successful eradication were significantly lower in the Billroth Ⅱ group than in the Billroth I group(0.13 ± 0.09 vs 0.31 ± 0.12, P = 0.029; 0.32 ± 0.24 vs 0.37 ± 0.13, P = 0.034, respectively).CONCLUSION: Patients with H. pylori following subtotal gastrectomy had a similar eradication rate to patients with an intact stomach. H. pylori eradication is recommended after subtotal gastrectomy.     

Health-related quality of life after curative resection for gastric adenocarcinoma

BACKGROUNDWith improved survival in gastric cancer patients, health-related quality of life has become an important clinical endpoint alongside primary oncological outcomes.AIMTo investigate health-related quality of life after various surgical procedures for gastric cancer treatment.METHODSThe validated Slovenian version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (QLQ-C30) and its gastric cancer-specific module (QLQ STO-22) was sent for self-completion to patients that underwent curative resection for gastric adenocarcinoma between January 2014 and December 2018 at our centre. In total, 116 patients responded. Scores were compared between patients after subtotal distal vs total gastrectomy and patients after subtotal distal gastrectomy with Billroth II vs Roux-en-Y reconstruction.RESULTSInterestingly, the extent of resection did not influence daily functioning; however, more dysphagia and eating restrictions were reported in patients after total gastrectomy when compared to patients after subtotal distal gastrectomy. Moreover, patients with Billroth II reconstruction after subtotal distal resection experienced worse physical and role functioning and reported more pain, fatigue and reflux compared to Roux-en-Y reconstruction.CONCLUSIONBased on our results, Roux-en-Y reconstruction after subtotal distal gastrectomy should be preferred over Billroth II reconstruction. The data obtained from this study will help surgeons when preoperatively informing their patients about expected functional outcomes after gastrectomy and enable them to ensure proper supportive care of their patients in the postoperative period.     

Impact of Scope Exchange from a Long Single Balloon Enteroscope to a Gastroscope during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy

Background/AimsEndoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is challenging to gastrointestinal endoscopists. The aim of this study was to evaluate the impact of scope exchange from a long single balloon enteroscope (SBE) to a gastroscope during SBE-assisted ERCP (SBE-ERCP) in patients with SAA.MethodsPatients who underwent SBE-ERCP between February 2019 and October 2020 were retrospectively identified. Intubation success, scope exchange success, cannulation success, and therapeutic success were analyzed along with complications.ResultsFifty-six patients with various SAAs underwent SBE-ERCP procedures, including Billroth II subtotal gastrectomy (B-II, n=13), pylorus-preserving pancreato-duodenectomy (PPPD, n=6), Roux-en-Y hepaticojejunostomy (REY HJ, n=4), and total gastrectomy with REY anastomosis (TG REY, n=33). Overall intubation, cannulation, and therapeutic success rates were 89.3%, 82.1%, and 82.1%, respectively. Therapeutic success rates did not differ significantly among the type of SAA. Successful scope exchange rate after successful intubation was significantly higher in native papilla (B-II and TG REY, 83.3%, 35/42) compared to bilioenteric anastomosis (PPPD and REY HJ, 0%, 0/8, p<0.001). Intubation success, scope exchange, and cannulation success were associated with therapeutic success (p<0.001). In multivariate analysis, successful scope exchange was the only factor related to cannulation success (p=0.02). The major complication rate was 1.8% (one perforation).ConclusionsSBE-ERCP is a safe and effective procedure to treat biliary problems in patients with SAA. Successful scope exchange may lead to higher therapeutic success by way of cannulation success.     

Endoscopic transpancreatic septotomy as a precutting technique for difficult bile duct cannulation

AIM: To evaluate the technique of transpancreatic septotomy(TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography(ERCP).METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth Ⅱ gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients(36 transpancreatic septotomies and 33 needle-knife sphincterotomies). RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy(NKS) groups were 97.2%(35/36) and 96.9%(32/33), respectively, which were not significantly different(P 0.05). Complications occurred in 11 cases, including acute pancreatitis(n = 6), bleeding(n = 2), and cholangitis(n = 3). The total frequency of complications in the TS group was lower than that in the NKS group(8.3% vs 24.2%, P 0.05).CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.     

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.     

Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy

AIM:To evaluate the effect of double balloon endoscope(DBE)on the endoscopic retrograde cholangio-pancreatography(ERCP)success rate in patients with a history of BillrothⅡ(BⅡ)gastrectomy.METHODS:From April 2006 to March 2007,32 patients with a BⅡgastrectomy underwent 34 ERCP attempts.In all cases,the ERCP procedures were started using a duodenoscope.If intubation of the afferent loop or reaching the papilla failed,we changed to DBE for the ERCP procedure(DBE-ERCP).We assessed the success rate of afferent loop intubation,reaching the major papilla,selective cannulation,possibility of therapeutic approaches,procedure-related complications,and the overall success rate.RESULTS:Among the 32 patients with a history of BⅡgastrectomy,the duodenoscope was successfully passed up to the papilla in 22 patients(69%),and cannulation was successfully performed in 20 patients(63%).Six patients(2 with failure in afferent loop intubation and 4 with failure in reaching the papilla)underwent DBE-ERCP.The DBE reached the papilla in all the 6 patients(100%)and selective cannulation was successful in 5 patients(83%).Four patients(67%)who had common bile duct stones were successfully treated.One patient underwent diagnostic ERCP only and the other one,in whom selective cannulation failed,was diagnosed with papilla cancer proven by biopsy.There were no complications related to the DBE.The overall ERCP success rate increased to 88%(28/32).CONCLUSION:The overall ERCP success rate increases with DBE in patients with a previous BⅡgastrectomy.     

Should peri-gastrectomy gastric acidity be our focus among gastric cancer patients?

AIM:To investigate the necessity and correctness of acid suppression pre-and post-gastrectomy among gastric carcinoma(GC)patients.METHODS:From June 2011 to April 2013,99 patients who were diagnosed with GC or adenocarcinoma of the gastroesophageal junction(typeⅡorⅢ)and needed surgical management were enrolled.They all underwent gastrectomy by the same operators[35undergoing total gastrectomy(TG)plus Roux-en-Y reconstruction,34 distal gastrectomy(DG)plus Billroth I reconstruction,and 30 proximal gastrectomy(PG)plus gastroesophagostomy].We collected and analyzed their gastrointestinal juice and tissues from the preoperational day to the 5th day post-operation,and 6 mo post-surgery.Gastric pH was detected with a precise acidity meter.Gastric juice contents including potassi-um,sodium and bicarbonate ions,urea nitrogen,direct and indirect bilirubin,and bile acid were detected using Automatic Biochemical Analyzer.Data regarding tumor size,histological type,tumor penetration and tumornode-metastasis(TNM)stage were obtained from the pathological records.Reflux symptoms pre-and 6 mo post-gastrectomy were evaluated by reflux disease questionnaire(RDQ)and gastroesophageal reflux disease questionnaire(GERD-Q).SPSS 16.0 was applied to analyze the data.RESULTS:Before surgery,gastric pH was higher than the threshold of hypoacidity(4.25±1.45 vs 3.5,P=0.000),and significantly affected by age,tumor size and differentiation grade,and potassium and bicarbonate ions;advanced malignancies were accompanied with higher pH compared with early ones(4.49±1.31vs 3.66±1.61,P=0.008).After operation,gastric pH in all groups was of weak-acidity and significantly higher than that pre-gastrectomy;on days 3-5,comparisons of gastric pH were similar between the 3 groups.Six months later,gastric pH was comparable to that on days 3-5;older patients were accompanied with higher total bilirubin level,indicating more serious reflux(r=0.238,P=0.018);the TG and PG groups had higher RDQ(TG vs DG:15.80±5.06 vs 12.26±2.14,P=0.000;PG vs DG:15.37±3.49 vs 12.26±2.14,P=0.000)and GERD-Q scores(TG vs DG:10.54±3.16 vs9.15±2.27,P=0.039;PG vs DG:11.00±2.07 vs 9.15±2.27,P=0.001)compared with the DG group;all gastric juice contents except potassium ion significantly rose;reflux symptom was significantly associated with patient’s body mass index,direct and indirect bilirubin,and total bile acid,while pH played no role.CONCLUSION:Acidity is not an important factor causing unfitness among GC patients.There is no need to further alkalify gastrointestinal juice both pre-and postgastrectomy.     

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.     

Effect of partial gastrectomy with Billroth II or Roux-en-Y anastomosis on postprandial and cholecystokinin-stimulated gallbladder contraction and secretion of cholecystokinin and pancreatic polypeptide

This prospective study was undertaken to determine the effect of partial gastrectomy without vagotomy on postprandial gallbladder contraction and secretion of cholecystokinin (CCK) and pancreatic polypeptide (PP) in 22 peptic ulcer patients randomly assigned to either Billroth II (N = 11) or Roux-en-Y (N = 11) anastomosis. The patients were studied within two weeks before surgery and at six months postoperatively. After surgery basal gallbladder volumes were larger than preoperatively (P less than 0.02). Integrated postprandial gallbladder contraction was not significantly affected by gastrectomy, either in the patients with Billroth II anastomosis (2276 +/- 268 vs 1985 +/- 362%/60 min) or in those with Roux-en-Y anastomosis (2045 +/- 327 vs 2445 +/- 352%/60 min) when studied pre- and postoperatively, respectively. Similarly, integrated postprandial plasma CCK secretion was not significantly changed by either Billroth II gastrectomy (200 +/- 31 vs 166 +/- 21 pM/60 min) or Roux-en-Y gastrectomy (146 +/- 26 vs 147 +/- 12 pM/60 min). However, integrated postprandial PP secretion was significantly (P less than 0.05) lower after Billroth II gastrectomy (6.8 +/- 2.4 vs 2.2 +/- 1.0 nM/60 min), while the reduction in plasma PP after Roux-en-Y gastrectomy just failed to reach statistical significance (6.0 +/- 1.5 vs 3.4 +/- 0.9 nM/60 min). Similarly, the PP response, but not the gallbladder response, to an intravenous bolus injection of 1 IDU CCK/kg body weight was significantly decreased after gastrectomy independent of the type of anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Retrieval-balloon-assisted enterography for ERCP after Billroth II gastroenterostomy and Braun anastomosis

AIM: To describe an optimal route to the Braun anastomosis including the use of retrieval-balloon-assisted enterography.METHODS: Patients who received a Billroth II gastroenterostomy (n = 109) and a Billroth II gastroenterostomy with Braun anastomosis (n = 20) between January 2009 and May 2013 were analyzed in this study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed under fluoroscopic control using a total length of 120 cm oblique-viewing duodenoscope with a 3.7-mm diameter working channel. For this procedure, we used a triple-lumen retrieval balloon catheter in which a 0.035-inch guidewire could be inserted into the “open-channel” guidewire lumen while the balloon could be simultaneously injected and inflated through the other 2 lumens.RESULTS: For the patients with Billroth II gastroenterostomy and Braun anastomosis, successful access to the papilla was gained in 17 patients (85%) and there was therapeutic success in 16 patients (80%). One patient had afferent loop perforation, but postoperative bleeding did not occur. For Billroth II gastroenterostomy, there was failure in accessing the papilla in 15 patients (13.8%). ERCP was unsuccessful because of tumor infiltration (6 patients), a long afferent loop (9 patients), and cannulation failure (4 patients). The papilla was successfully accessed in 94 patients (86.2%), and there was therapeutic success in 90 patients (82.6%). Afferent loop perforation did not occur in any of these patients. One patient had hemorrhage 2 h after ERCP, which was successfully managed with conservative treatment.CONCLUSION: Retrieval-balloon-assisted enterography along an optimal route may improve the ERCP success rate after Billroth II gastroenterostomy and Braun anastomosis.     

Effect of partial gastrectomy on serum anti-Helicobacter pylori immunoglobulins in peptic ulcer patients

Since biliary enterogastric reflux is suggested to eradicate gastric infection withHelicobacter pylori (HP), we have investigated in a prospective randomized study the effect of partial gastrectomy with either Billroth II or Roux-en-Y anastomosis on infection with HP as assessed by the titers of IgG and IgA antibodies against HP in serum. These antibodies were measured by ELISA in serum of 22 patients before and at 10 days and 6, 15, and 24 months after either Billroth II (N=11) or Roux-en-Y (N=11) gastrectomy for peptic ulcer. All patients had HP demonstrated in their preoperative endoscopic gastric biopsies. The preoperative serum IgA antibodies against HP (anti-HP IgA) were increased in 20 of the 22 patients (range 0.21–1.69) while the IgG antibodies (anti-HP IgG) were increased in all 22 patients (range 0.38–1.31). Four of the Billroth II patients had clearance of HP from gastric biopsies accompanied by rapid and pronounced decrease of anti-HP IgA. In contrast, the patients with Roux-en-Y gastrectomy and the Billroth II patients with persistent HP infection had no change in anti-HP IgA after surgery. Anti-HP IgG showed variable results in the four patients without gastric HP infection and was not affected by gastrectomy in the patients with persistent HP infection. We concluded that serum anti-HP IgA, but not anti-HP IgG, is helpful in identifying those patients in whom HP is no longer demonstrable after Billroth II gastrectomy. Gastrectomy with Roux-en-Y anastomosis had no effect on gastric HP infection.     

Esophagojejunostomy after laparoscopic total gastrectomy by Or VilTM or hemi-double stapling technique

AIM: To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.METHODS: This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group Ⅰ underwent esophagojejunostomy using a transorally-inserted anvil(Or VilTM), while patients in Group Ⅱ underwent esophagojejunostomy using the hemi-double stapling technique(HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients' baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were comparedbetween the two groups. The primary endpoint was evaluation of the surgical outcome(operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation(operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared. RESULTS: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups(287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group Ⅱ compared with Group I(47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intraoperative blood loss(96.4 ± 32.7 m L vs 88.2 ± 36.9 m L, P = 0.28), time to defecation(3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation(3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet(7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization(10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups(73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group Ⅱ(32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P 0.001).CONCLUSION: Anvil insertion was faster and easier using the HDST technique compared with Or VilTM, and was more cost-effective. There was no significant difference in safety.     

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/Aims

Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.

Methods

Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.

Results

Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.

Conclusions

Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.     

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth Ⅱ gastrectomy patients

Background: Endoscopic papillary balloon dilation(EPBD) for common bile duct(CBD) stones removal in Billroth Ⅱ gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth Ⅱ gastrectomy patients.Methods: The records of patients with previous Billroth Ⅱ gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography(ERCP) between July 1, 2008 and September 1,2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events,and stone recurrence were analyzed.Results: A total of 83 patients with previous Billroth Ⅱ gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth Ⅱ gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients(85.7%). ERCP-related adverse events was in 3 ERCP procedures(5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients(12.2%) had stone recurrence after a median period of22.5 months(range 6–71 months) from the end of stone removal treatment. Female [odds ratio(OR) = 11.352; 95% confidence interval(95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy(OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.Conclusions: At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth Ⅱ gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.     

Colangiopancreatografía retrógrada endoscópica en pacientes con alteraciones de la anatomía gástrica por cambios posquirúrgicos

Introduction

In patients who have undergone partial gastric resections, the difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) is increased due to the resulting anatomic abnormality.

Aim

To review our experience of ERCP in patients with Billroth II gastrectomy and other types of gastrectomy (Billroth I and indeterminate) in our center.

Material and methods

We included all patients with Billroth II gastrectomy or other types of gastrectomy undergoing ERCP in a 19-year period.

Results

We included 233 patients (91% men and 9% women) from 1993 to 2012. A total of 88.4% of the patients had undergone Billroth II and 11.6% had undergone other types of gastrectomy, with an ERCP success rate of 51.9% and 55.6%, respectively. The most common causes of failure were inability to cannulate (44%) and failure to identify the papilla (39.6%). The final diagnosis was choledocholithiasis in 31.8%. The mean number of sessions was 1.09. The complications rate was 2.6%.

Conclusions

The success of ERCP is influenced by the technical difficulty. For this reason, the success rate in our center was slightly over 50%, but with few complications.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.     

Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy

AIM:To evaluate the effectiveness of a short-type single-balloon-enteroscope(SBE) for endoscopic retrograde cholangiopancreatography(ERCP) in patients with a reconstructed intestine.METHODS:Short-type SBE was developed to perform ERCP in postoperative patients with a reconstructed intestine.Short-type SBE is a direct-viewing endoscope with the following specifications:working length,1520 mm;total length,1840 mm;channel diameter,3.2 mm.In addition,short-type SBE has a water-jet channel.The study group comprised 22 patients who underwent 31 sessions of short-type SBE-assisted ERCP from June 2011 through May 2012.Reconstruction was performed by Billroth-Ⅱ(B-Ⅱ) gastrectomy in 6 patients(8 sessions),Roux-en-Y(R-Y) gastrectomy in 14 patients(21 sessions),and R-Y hepaticojejunostomy in 2 patients(2 sessions).We retrospectively studied the rate of reaching the blind end(papilla of Vater or choledochojejunal anastomosis),mean time required to reach the blind end,diagnostic success rate(defined as the rate of successfully imaging the bile and pancreatic ducts),therapeutic success rate(defined as the rate of successfully completing endoscopic treatment),mean procedure time,and complications.RESULTS:Among the 31 sessions of ERCP,the rate of reaching the blind end was 88% in B-Ⅱ gastrectomy,91% in R-Y gastrectomy,and 100% in R-Y hepaticojejunostomy.The mean time required to reach the papilla was 18.3 min in B-Ⅱ gastrectomy,21.1 min in R-Y gastrectomy,and 32.5 min in R-Y hepaticojejunostomy.The diagnostic success rates in all patients and those with an intact papilla were respectively 86% and 86% in B-Ⅱ gastrectomy,90% and 87% in R-Y gastrectomy,and 100% in R-Y hepaticojejunostomy.The therapeutic success rates in all patients and those with an intact papilla were respectively 100% and 100% in B-Ⅱ gastrectomy,94% and 92% in R-Y gastrectomy,and 100% in R-Y hepaticojejunostomy.Because the channel diameter was 3.2 mm,stone extraction could be performed with a wire-guided basket in 12 sessions,and wireguided intraducta