A new operative technique for the resection of gastric tube cancer by means of lifting the anterior chest wall and videoscope-assisted surgery

SUMMARY.  The prolonged survival of patients receiving surgery for esophageal cancer has led to an increased incidence of adenocarcinoma arising in the gastric tube used for reconstruction (gastric tube cancer). In patients with advanced gastric tube cancer, resection of the gastric tube should be considered, but currently available procedures are very invasive. In patients undergoing curative surgery for gastric tube cancer that has developed after reconstruction through the retrosternal route, the gastric tube is usually resected through a median sternotomy, followed by reconstruction with the colon. However, postoperative complications often occur and treatment outcomes remain poor. We developed a new surgical technique for gastric tube resection without performing a sternotomy in patients with gastric tube cancer who had previously undergone reconstruction through the retrosternal route. Our technique was used to treat two patients. Two Kirschner wires were passed subcutaneously through the anterior chest; the chest was lifted to extend the retrosternal space and secure an adequate surgical field. The stomach was separated from the surrounding tissue under videoscopic guidance. Total resection of the gastric tube was done. The retrosternal space was used to lift the jejunum. Roux-en-Y reconstruction was performed. Neither patient had suture line failure or surgical site infection. Their recovery was uneventful. Our surgical technique has several potential advantages including (i) reduced surgical stress; (ii) the ability to use the retrosternal space for reconstruction after gastric tube resection; and (iii) a reduced risk of serious infections such as osteomyelitis in patients with suture line failure. Our findings require confirmation by additional studies.     

A comparative study of the lengths of different reconstruction routes used after thoracic esophagectomy

Background

A challenge in esophageal reconstruction after esophagectomy is that the distance from the neck to the abdomen must be replaced with a long segment obtained from the gastrointestinal tract. The success or failure of the reconstruction depends on the blood flow to the reconstructed organ and the tension on the anastomotic site, both of which depend on the reconstruction distance. There are three possible esophageal reconstruction routes: posterior mediastinal, retrosternal, and subcutaneous. However, there is still no consensus as to which route is the shortest.

Methods

The length of each reconstruction route was retrospectively compared using measurements obtained during surgery, where the strategy was to pull up the gastric conduit through the shortest route. The proximal reference point was defined as the left inferior border of the cricoid cartilage and the distal reference point was defined as the superior border of the duodenum arising from the head of the pancreas.

Results

This study involved 112 Japanese patients with esophageal cancer (102 men, 10 women). The mean distances of the posterior mediastinal, retrosternal, and subcutaneous routes were 34.7?±?2.37 cm, 32.4?±?2.24 cm, and 36.3?±?2.27 cm, respectively. The retrosternal route was significantly shorter than the other two routes (both p?<?0.0001) and shorter by 2.31 cm on average than the posterior mediastinal route. The retrosternal route was longer than the posterior mediastinal route in only 5 patients, with a difference of less than 1 cm.

Conclusion

The retrosternal route was the shortest for esophageal reconstruction in living Japanese patients.

     

Appropriate routes of reconstruction following transthoracic esophagectomy

BACKGROUND/AIMS: The effectiveness of reconstructive methods after esophagectomy remains controversial. METHODOLOGY: A total of 211 patients who underwent transthoracic esophagectomy and esophagogastric anastomosis using the gastric conduit were enrolled in this study. A retromediastinal approach was used in 79 patients and a retrosternal approach in 132. The surgical outcomes were compared between the two groups. RESULTS: In the retrosternal group, anastomotic leakage (26.5%), stenosis of the anastomosis (13.6%), and respiratory complications (18.2%) were frequently observed. Five patients died of aspiration pneumonia probably due to stenosis of the anastomotic site in the retrosternal group. In the retromediastinal group, two patients died from bleeding of a peptic ulcer in the gastric conduit. Partial resection of the manubrium significantly reduced the incidence of leakage in the retrosternal group (4/29 vs. 31/68, p=0.0305). Retrosternal approach and stage were independent prognostic factors for overall survival whereas only stage was an independent prognostic factor for disease-specific survival. CONCLUSIONS: Retrosternal reconstruction is suggested as the unwillingly adopted method of choice after palliative esophagectomy (R2) for the following radiotherapy. Partial resection of the bony structures can be used to prevent postoperative morbidity in this operative procedure. Retromediastinal reconstruction is the possible method of choice in patients receiving curative esophagectomy.     

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.     

Comparison between different reconstruction routes in esophageal squamous cell carcinoma

AIM:To compare postoperative complications and prognosis of esophageal squamous cell carcinoma patients treated with different routes of reconstruction. METHODS:After obtaining approval from the Medical Ethics Committee of the Sun Yat-Sen University Cancer Center, we retrospectively reviewed data from 306 consecutive patients with histologically diagnosed esophageal squamous cell carcinoma who were treated between 2001 and 2011. All patients underwent radical McKeown-type esophagectomy with at least two-field lymphadenectomy. Regular follow-up was performed in our outpatient department. Postoperative complica-tions and long-term survival were analyzed by treatment modality, baseline patient characteristics, and operative procedure. Data from patients treated via the retrosternal and posterior mediastinal routes were compared. RESULTS:The posterior mediastinal and retrosternal reconstruction routes were employed in 120 and 186 patients, respectively. Pulmonary complications were the most common complications experienced during the postoperative period (46.1% of all patients; 141/306). Compared to the retrosternal route, the posterior mediastinal reconstruction route was associated with a lower incidence of anastomotic stricture (15.8% vs 27.4%, P = 0.018) and less surgical bleeding (242.8 ± 114.2 mL vs 308.2 ± 168.4 mL, P 0.001). The median survival time was 26.8 mo (range:1.6-116.1 mo). Upon uni/multivariate analysis, a lower preoperative albumin level (P = 0.009) and a more advanced pathological stage (pT; P = 0.006; pN; P 0.001) were identified as independent factors predicting poor prognosis. The reconstruction route did not influence prognosis (P = 0.477). CONCLUSION:The posterior mediastinal route of reconstruction reduces incidence of postoperative complications but does not affect survival. This route is recommended for resectable esophageal squamous cell carcinoma.     

Anterior vs. Posterior Mediastinal Routes in Colon Interposition after Esophagectomy

Background/Aims: Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. Methodology: We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Results: Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Conclusions: Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.     

Does the interponat affect outcome after esophagectomy for cancer?*

Clinical decision-making in esophageal cancer surgery is a process of balancing the risks of treatment against potential benefits, such as survival and quality of life. Various options are available for esophageal reconstruction. While these reconstructive options do not directly have an impact on cancer survival, they do affect operative morbidity and long-term quality of life. The affect of various interponats (reconstructive conduits) and routes of reconstruction on operative morbidity and foregut function is reviewed. Gastric interponats are preferred for esophageal reconstruction because of their reliable vascularity and the relative simplicity of the reconstructive operation. Colon interponats supposedly provide better long-term function as an esophageal substitute (unproven), but at the cost of increased operative complexity and morbidity. Colon interposition is therefore reserved for situations in which gastric transposition is not feasible. Both posterior and anterior mediastinal routes of gastric interponat reconstruction are acceptable (meta-analysis of randomized controlled trials). Posterior mediastinal reconstruction is usually preferred when a complete (R0) resection has been accomplished. Anterior mediastinal reconstruction may prevent secondary dysphagia after incomplete (R1, R2) resections.     

Surgical treatment of oesophageal cancer

Various reconstructive conduits and routes of reconstruction have an impact on operative morbidity and foregut function in patients undergoing oesophagectomy. Advantages of a fundus rotation gastroplasty are the better blood supply and the greater length of the gastric tube and its possible impact on anastomotic complications. For a subgroup of patients with oesophageal carcinoma limited to the lamina propria vagal-sparing oesophagectomy seems to be a good alternative in terms of quality of life to preserve gastric secretory, motor, and reservoir function. Posterior mediastinal reconstruction is usually preferred when complete resection (R0) has been accomplished. Anterior mediastinal reconstruction may secondary prevent dysphagia after incomplete resections due to tumour recurrence (R0, R1). However, for all presently available surgical approaches in the treatment of oesophageal cancer qualified studies (prospective randomised) are needed. In addition, randomized trials are needed to identify the specific subgroups of patients who benefit from neoadjuvant or adjuvant radiochemotherapy.     

Gastrectomy circumstances that influence early postoperative outcome

BACKGROUND/AIMS: Despite decreasing mortality, gastric resection is still a procedure of significant morbidity. METHODOLOGY: Factors predicting post-gastrectomy outcome over 3 years in a tertiary care cancer center, single-surgeon experience were analyzed. RESULTS: Thirty-four patients who underwent total or partial gastrectomy at the City of Hope Cancer Center between 11/1996 and 11/1999 were analyzed. There were 21 males and 13 females, with a median age of 61 years (range: 36-97). Diagnoses included gastric malignancy (n = 28), hemorrhage from diffuse gastritis (n = 4), gastric necrosis with perforation (n = 1), and an aortogastric fistula (n = 1). The operative intent was curative in 22, and palliative in 6 cancer patients. Procedures included total (n = 14), subtotal (n = 9), distal (n = 8), and proximal gastrectomy (n = 3). Reconstruction techniques were Roux-Y (n = 25), BII (n = 5), primary esophagogastric anastomosis (n = 3), and primary gastric closure (n = 1). Twenty patients had prior abdominal operations (59%); 10 underwent resection of additional organs (29%), including 2 splenectomies. The median lymph node count was 24, and 20 cancer patients had a R0 resection (71%). Postoperative complications occurred in 14 patients (41%; major: 26%), with 3 in-hospital deaths and one 90-day fatality (90-day mortality: 12%). Predictors of complications were benign diagnosis (p = 0.01), emergency procedure (p = 0.01), and splenectomy (prior or concurrent) (p = 0.02). Cancer diagnosis (vs. benign) and nonemergent gastrectomy (vs. emergency) were each associated with lower mortality (4 vs. 50%, p = 0.01), median length of stay (12 vs. 19 d, p = 0.02), and tube feed duration (7 vs. 194 d, p = 0.04). Gastrectomies for cancer with curative intent (vs. palliative or therapeutic) had no mortality (p = 0.004), a major complication rate of 14% (p = 0.02), and a median stay of 12 days (p = n.s.). For patients with gastric cancer, pathologic stage was the only multivariate predictor of survival (p = 0.04) at a median follow-up of 9 months (15 for survivors); a median survival for patients with potentially curable disease (stage IA-IIIB) has not yet been reached. CONCLUSIONS: Gastrectomies for cancer, especially when done electively with curative intent, can lead to excellent postoperative recovery. Palliative gastrectomies or emergency procedures for "benign" conditions have significantly more complicated outcomes.     

Reflux esophagitis and columnar‐lined esophagus after cervical esophagogastrostomy (following esophagectomy)

Reflux esophagitis (RE) and columnar‐lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow‐up is necessary for such patients irrespective of the route of esophageal reconstruction.     

Omentoplasty for cervical esophagogastrostomy following radical esophagectomy with three-field dissection

BACKGROUND/AIMS: Anastomotic leakage is the main cause of postoperative mortality and incidence of which, following three-field lymph node dissection, is around 30%. The study was undertaken to investigate the role of omentoplasty to reinforce cervical esophagogastrostomy with the expectation of lowering the rate of anastomotic leakage after radical esophagectomy with three-field lymph node dissection. METHODOLOGY: Between July 1995 and Dec 1997, a total of 32 patients underwent total thoracic esophagectomy with three-field lymph node dissection and cervical esophagogastrostomy. Eleven patients were stage IIA, 3 stage IIB, 5 stage III and 13 stage IV. After radical esophagectomy and lymph node dissection, several omental branches of the gastroepiploic vessels remained to supply a gastric tube. An end-to-side cervical esophagogastrostomy was performed on the posterior wall of the gastric tube using a circular stapler. The omentoplasty--wrapping the esophagogastrostomy--was performed. A retrosternal route for reconstruction was used in 23 patients and a posterior mediastinal route in 9 patients. RESULTS: Esophageal anastomotic leakage occurred in only 1 patient, 3.1% overall. There was neither pyothorax nor mediastinitis. There was no lethal anastomotic leakage. Later, 2 patients (6.2%) developed an anastomotic stricture that required balloon dilatation. CONCLUSIONS: Omentoplasty to reinforce cervical esophagogastrostomy decreases anastomotic failure following radical esophagectomy with three-field lymph node dissection.     

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand‐assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA‐preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.     

What influences the acidity in the gastric conduit in patients who underwent cervical esophagogastrostomy for cancer?

The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24‐h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the ¹³C‐urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH < 4 was reduced after surgery and was significantly less in patients with H. pylori infection compared with those without H. pylori infection throughout the period from 1 week before surgery to 1 year after surgery. Duodenogastric reflux (DGR) assessed by % time absorbance > 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short‐term after surgery, but not in the long‐term after surgery.     

Ten cases of gastro‐tracheobronchial fistula: a serious complication after esophagectomy and reconstruction using posterior mediastinal gastric tube

Gastro‐tracheobronchial fistula (GTF) is a rare but life‐threatening complication specifically observed after esophagectomy and reconstruction using posterior mediastinal gastric tube. Ten cases of GTF were encountered in three hospitals in 2000–2009. Their clinicopathological, surgical, and postoperative care are summarized, together with a review of previously reported cases. GTF was classified as anastomotic leakage (n= 5), gastric necrosis (n= 4), and gastric ulcer type (n= 1). The anastomotic leakage type appeared about 2 weeks (postoperative day [POD]: 8–35) after esophagectomy, was located in the cervical or higher thoracic trachea. Breathing and pneumonia were controlled by tracheal tube placed in the distal of fistula. The gastric necrosis type was noted in patients who developed necrosis of the upper part of the gastric tube and abscess formation behind the tracheal wall, at POD 20–36 around the carina, the site of pronounced ischemia. Due to the large fistula around the carina, emergency surgery with muscle patch repair was frequently required for the control of aspiration pneumonia. Patients of the gastric ulcer type had peptic ulcer in the lesser curvature of the gastric tube, which perforated into the right bronchus long after surgery (POD 630). With respect to tracheobronchial factors, preoperative chemoradiation (three cases) and pre‐tracheal node dissection (three cases) tended to increase the risk of GTF. Closure of GTF by surgery (muscle patch repair) was successful in four cases and by nonsurgical treatment in three cases. In one case, stable oral intake was achieved by bypass operation without closure of GTF. Hospital death occurred in three cases. Understanding the pathogenesis and treatment options of GTF is important for surgeons who deal with esophageal cancer.     

Evaluation of surgical treatment for patients with gastric cancer who are over 80 years of age.

BACKGROUND/AIMS: The aim of this study is to evaluate whether super-elderly patients (> or = 80) with gastric cancer may be appropriate candidates for an R2/R3 (extended) gastrectomy. METHODOLOGY: The study evaluated 1334 patients with gastric cancer treated over the past 15 years, who were over 40 years of age. They were divided into three groups according to age: Super-elderly patients who were over 80 (group A; n=60), those aged 60-79 (group B; n=703) and those aged 40-59 (group C; n=571). RESULTS: The incidence of concomitant systemic disorders was higher in group A than in either group B or group C (65% vs. 53.2% vs. 34%) (p<0.0001). The resection rates were similar (88.3% vs. 93.7% vs. 96.1%), however, the incidence of a total gastrectomy, an R2/R3 dissection, or a combined resection of other organs was much lower in group A than those in the other groups (p<0.005). The survival curves of patients after a curative resection were not significant, however, 34.4% of the super-elderly patients died of other causes and the 5-year survival rates including other cause of death were poorer in groups A and B than those in group C (p<0.01). In group A, patients receiving an R2/R3 dissection had a two-fold higher incidence of post-operative complications over those receiving an R0/R1 (regional) dissection, however, they also had a better prognosis whether or not other causes of death were considered. CONCLUSIONS: We, therefore, conclude that an R2/R3 gastrectomy is basically appropriate for super-elderly patients, as long as they demonstrate a good risk. However, the short-term results should also be considered.     

Acid-related diseases following retrosternal stomach interposition.

BACKGROUND/AIMS: Esophagectomy and reconstruction with retrosternal stomach interposition implies bilateral truncal vagotomy, which supposedly causes gastric functional impairment. METHODOLOGY: Esophagectomy and reconstruction with retrosternal stomach interposition was performed on 15 men (mean age: 58.4 years) and 3 women (mean age: 43.6 years). The stomach was pedicled on the right gastric and right gastroepiploic artery without performing pyloroplasty. The cervical side-to-end anastomosis was sutured manually. The functional results were assessed 2-4 years postoperatively, by determining 24-hour qualitative intragastric pH-measurement, fluoroscopical gastric emptying studies, fasting gastrin levels, and endoscopy with biopsy studies. RESULTS: Endoscopy and biopsy confirmed esophagitis in 12 patients, gastritis in 15 and a gastric ulcer in 1 case. Fluoroscopic examination documented a normal passage of contrast medium in 17, slight impairment in 1 case treated by balloon dilatation of the pylorus. Qualitative intragastric pH-measurement revealed a total pH < 3 in 22.5-98.05% of measuring events (mean: 74.31%) within 24 hours, in 18 cases. Only 4 patients had pH < 3 in less than 50%. Fasting gastrin levels (normal range: 25-110 mU/L) varied from 48.78 mU/L-168.20 (mean: 85.23 mU/L). Only 3 patients had levels > 110 mU/L (maximum: 168.20 mU/L). CONCLUSIONS: Acid-related diseases may also occur after truncal vagotomy and retrosternal stomach interposition. Routine follow-up endoscopy and biopsy studies should be done to prevent inflammatory complications and maintain the patient's quality of life.     

Therapeutic potential of duodenal electrical stimulation for obesity: acute effects on gastric emptying and water intake

OBJECTIVES: No satisfactory treatment is available for obesity. Previous animal studies suggested the therapeutic potential of intestinal electrical stimulation for obesity. The aim of this study was to investigate the effects of duodenal electrical stimulation (DES) on gastric emptying and water intake in healthy humans. METHODS: The study was performed in 12 healthy volunteers intubated with a feeding tube in the duodenum under endoscopy. There were three ring electrodes at the end tip of the tube and the two distal electrodes were used for recording and electrical stimulation. On two separate days, each subject underwent a session of DES with various stimulation parameters, a water-intake test with DES or with sham-DES, and a gastric-emptying test with DES or with sham-DES. RESULTS: DES did not induce any noticeable dyspeptic symptoms. The amount of water drunk by the subjects was significantly reduced from 897 +/- 88 ml with sham-DES to 673 +/- 63 ml with DES (p < 0.002). The mean T(50) of gastric emptying was significantly increased from 113.1 +/- 10.0 min with sham-DES to 176.5 +/- 20.8 min with DES state (p < 0.005). The gastric retention at 2 h was increased with DES (42.8 +/- 4.5% vs 61.4 +/- 4.7%; p < 0.02). CONCLUSIONS: DES delays gastric emptying and reduces water intake. It may have a potential application for the treatment of obesity.     

Endoscopic full-thickness resection with sutured closure in a porcine model

BACKGROUND: Some early gastric cancers might be advantageously staged and treated by full-thickness resection if secure methods for closing the defect were available. The aim of this study was to test the feasibility of full-thickness gastric resection. METHODS: Full-thickness gastric resections were performed by using a ligating device without submucosal injection in survival studies in pigs (n = 8). The defects were closed by using new methods for suturing, locking, and cutting thread through a 2.8-mm accessory channel. Stitches (n = 2-4) were placed close to the target area before resection. OBSERVATIONS: Full-thickness resections (n = 8) were performed. The pigs survived without incident for 21 to 28 days. Healing of the suture site was evident at follow-up endoscopy. Suture sites were water tight. The pull-out force with stitches by using this new sewing method was significantly higher than with endoscopic clips (20.3 N +/- 0.94 vs. 2.2 N +/- 0.42, p < 0.05). CONCLUSIONS: Endoscopic full-thickness resection with sutured defect closure was feasible and appeared safe in these survival experiments.     

Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan

BACKGROUND: The Japanese population is rapidly aging, and the actual number of elderly patients with gastric cancer, including early cancer, has been increasing, even though the standardized incidence of gastric cancer in the population is decreasing. The optimal treatment for these patients remains a challenge to the surgeon. The aim of this retrospective analysis was to describe the results of gastrectomy and EMR for early gastric cancer in elderly patients (80 years of age and over). METHODS: This is a retrospective review of 93 elderly patients who had undergone gastrectomy or EMR at the National Cancer Center Hospital for early gastric cancer. EMR was performed aiming en bloc local resection with a clear curative margin (R0). The clinicopathologic characteristics, comorbidity, postoperative mortality, and outcome were recorded. RESULTS: Gastrectomy was performed in 44 patients (surgery group) and EMR in 49 patients (EMR group). There were significant differences in mean tumor size (p < 0.05), histologic type (p < 0.05), and depth of tumor invasion (p < 0.05) between the two groups. There was no significant difference in comorbidity between the two groups. No operative death was reported in either group. In the EMR group, 7 patients were reported to have recurrence of local disease and two patients died of advanced disease. There were no significant differences in the overall 3-year survival rate or the 5-year survival rate between the surgery group and EMR group (73.5% vs. 82.5% and 55.0% vs. 62.5%, respectively). CONCLUSIONS: EMR (R0) resection was performed safely in the elderly, and the overall results were excellent, the same as the results with gastrectomy. Gastrectomy can still be performed if EMR is unsuccessful.     

Feeding catheter gastrostomy at esophagectomy with gastric tube reconstruction through posterior mediastinal route

We introduce our novel and original idea of placing a feeding catheter gastrostomy (FCG) at esophagectomy with gastric tube reconstruction through the posterior mediastinal route. The 9-Fr catheter was inserted into the jejunum through the gastric tube by the creation of submucosal and Witzel tunnels on the gastric antrum. Among the 45 patients who underwent FCG, the catheter was guided to the anterior abdominal wall through the sub-diaphragm route in 25 patients (group A) or the extra-peritoneal route with the overlapping of catheter entry by the omentum in 20 patients (group B). There were no cases of spontaneous catheter prolapse or bowel obstruction. Five out of 45 patients (11.1%), including 4 (16%) in group A and 1 (5%) in group B, showed mild and transient localized peritonitis after catheter removal. The extra-peritoneal route with omental cover is recommended for safe indwelling catheterization. FCG is useful for avoiding jejunostomy-related bowel obstruction.