Is prophylactic placement of drains necessary after subtotal gastrectomy？

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.
METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.
RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）.
CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.     

Accelerated rehabilitation with early postoperative oral feeding following gastrectomy

BACKGROUND/AIMS: To evaluate the safety and efficacy of early oral feeding in patients undergoing gastrectomy. METHODOLOGY: One hundred patients undergoing gastrectomy were studied. Patients in the early oral feeding group (Early group) began a liquid diet within 48 hours after operation and patients within the Traditional group received nothing by mouth until the resolution of the ileus. All of the patients were monitored for vomiting, abdominal distention, length of ileus, tolerance of regular diet, duration of intravenous fluid administration, length of hospitalization, and complications. RESULTS: The time to flatus was 55.5+/-12.5 hours and 78.0+/-22.2 hours in the Early and Traditional group, respectively (p<0.05). And fasting period was 2.14+/-1.08 days and 5.93+/-2.35 days in the Early and Traditional group, respectively (p<0.05). In addition, duration of intravenous fluid administration was shorter in the patients in the Early group compared with Traditional group (5.7+/-1.7 days vs. 9.2+/-3.9 days, p<0.05). As a result, length of postoperative hospitalization in the patients in the Early group was significantly shorter than those in the Traditional group (16.2+/-5.3 days vs. 23.4+/-9.8 days, p<0.05). The incidence of complications including nausea, vomiting, anastomotic leak and wound infection occurred equally in both groups. CONCLUSIONS: Early oral feeding after gastrectomy is safe, with no evidence of increased morbidity, and early postoperative oral feeding is also highly effective in reducing hospital stay.     

腹腔镜早期胃癌根治术的临床研究

目的:探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用。方法:回顾性分析2004年10月至2009年12月间79例接受腹腔镜胃癌根治术的早期胃癌患者的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理和随访等。结果:除1例中转开腹手术外,其余78例均在腹腔镜下完成胃切除和淋巴结清扫,其中腹腔镜远端胃切除术74例,近端胃切除术2例,全胃切除术2例;腹腔镜下D1+α式淋巴结清扫34例,D1+β式淋巴结清扫15例,D2式淋巴结清扫29例。手术时间为(202.9±45.6)min,术中失血(144.5±146.5)mL,术后排气时间(2.8±1.0)d,术后住院天数为(11.3±5.6)d,8例(10.1%)患者出现腹腔内出血、吻合口漏、小肠梗阻等,经手术和非手术治疗后痊愈。手术上、下切缘距离肿瘤为(4.0±1.9)cm和(3.6±1.7)cm,手术平均清扫淋巴结(13.1±6.5)枚,其中有3例(3.8%)发现淋巴结转移。术后随访2～64个月,均无肿瘤复发和远处转移。结论:腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的手术方法。     

Gasless laparoscopy-assisted distal gastrectomy for early cancer via mini-laparotomy using an abdominal wall lift

BACKGROUND/AIMS: To investigate the technical ease and results of gasless laparoscopy-assisted distal gastrectomy with lymph node dissection via mini-laparotomy using abdominal wall lift for early gastric cancer. METHODOLOGY: We submitted 20 patients to laparoscopy-assisted distal gastrectomy for early gastric cancer located in the middle or lower stomach. The initial 10 cases underwent perigastric lymph node dissection (D1), and the subsequent 10 cases received further dissection around the left gastric and common hepatic arteries (D1 + a). Mini-laparotomy was placed at the beginning of the procedure. We lifted up the laparotomy and the subcutaneous tissue around the umbilicus by retractors. We accomplished the dissection, resection and reconstruction mainly via the mini-laparotomy using a direct view and a laparoscopic image. RESULTS: Two cases were converted to open. The operative time was significantly longer in D1 + a (225 +/- 49 min) than in D1 (172 +/- 38 min). Blood loss was significantly more in D1 + a (247 +/- 155 mL) than in D1 (109 +/- 60 mL). There was no difference between the two groups in terms of days to first flatus, first oral intake or discharge from the hospital. Postoperative complications included 2 wound infections each in D1 and D1 + a group, and 1 anastomotic stenosis in D1 + a group. CONCLUSIONS: Gasless laparoscopy-assisted distal gastrectomy with D1 + a via mini-laparotomy using abdominal wall lift seems to be feasible and useful for early gastric 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.     

The usefulness of intraoperative needle decompression of the colon during radical gastrectomy--a prospective and randomized trial

BACKGROUND/AIMS: Intraoperative colonic distension is associated with postoperative ileus, which contributes to delayed hospital discharge. A randomized and prospective study was conducted, to evaluate the usefulness of intraoperative needle decompression of the colon during radical gastrectomy for gastric cancer. METHODOLOGY: Fifty patients that had received subtotal or total gastrectomy for gastric cancer were randomly assigned to either a non-decompression (n=27) or a decompression group (n=23). Prior to the main procedure, the transverse or right colon was pulled up, and a 19-gauge disposable needle connected to suction was introduced to the colon through the taenia site of anterior wall. Gas collected in the colon was aspirated out. The time to the first postoperative passage of flatus or feces was measured precisely to evaluate the restoration of bowel function. Additional measures of outcome were the operation time, the complication rate, and hospital stay. RESULTS: Demographic details, pathologic features, operation time, complication rate and hospital stay were not different between the two groups. A collapsed colon was required for good surgical exposure and easy manipulation. No unexpected complication related to this procedure was found. The first flatus was 6.8 hours sooner in the decompression group than in the non-decompression, though this result was not statistically significant. CONCLUSIONS: This technique is a simple and safe procedure for intraoperative colon decompression during radical gastrectomy.     

Changes in plasma ghrelin concentration immediately after gastrectomy in patients with early gastric cancer

Although the majority of circulating ghrelin originates from the stomach, no prospective study of the proportion of ghrelin derived from the stomach has been reported. Patients with early gastric cancer who underwent gastric resection were divided into three groups according to the extent and site of gastric resection: subtotal gastrectomy group (n = 24), proximal gastrectomy group (n = 4), and total gastrectomy group (n = 12). Patients with advanced gastric cancer who underwent gastrojejunostomy without gastrectomy served as the bypass group (n = 5). Blood samples were collected from all patients preoperatively, at 1 h after gastric resection or gastrojejunostomy, and on postoperative d 1, 3, and 7. The plasma ghrelin level was determined in all samples and expressed as a percentage of the preoperative level. In the bypass group, no significant drop in the ghrelin level was observed at 1 h after gastrojejunostomy, and the ghrelin level remained stable through postoperative d 7. In the subtotal gastrectomy group, the ghrelin concentration reached a nadir of 38.8 +/- 12.9% of preoperative levels at 1 h after gastric resection and then gradually increased to 88.1 +/- 13.2% by postoperative d 7. In the proximal gastrectomy group, the nadir ghrelin level was 24.5 +/- 15.4% at 1 h after gastric resection and was followed by a gradual recovery. However, the recovery rate was slower than that in the subtotal gastrectomy group, with the ghrelin level reaching only 47.6 +/- 18.8% by postoperative d 7 (P < 0.05). In the total gastrectomy group, the nadir ghrelin level was 28.6 +/- 11.1% at 1 h after gastric resection and remained at 30.0 +/- 13.2% until postoperative d 7. These results suggest that compensatory ghrelin production can occur in the remnant stomach after the surgical removal of part of the stomach and that the proximal fundus is more important than the distal antrum and body in terms of the capacity for ghrelin production. The principal site of ghrelin production is clearly the stomach, which contributes 70% of the circulating ghrelin concentration.     

Gastric emptying after segmental gastrectomy for early cancer in the middle part of the stomach.

BACKGROUND/AIMS: We evaluated the quality of life and gastric emptying in patients who had undergone a segmental gastrectomy to treat early gastric cancer in the middle part of the stomach. METHODOLOGY: Thirty patients were considered in this study. Their mean age was 65.5 years (range: 44-83). All of the patients were free from recurrence of their cancer in the follow-up period. This ranged from 5 to 50 months (mean 30). Patients were interviewed at regular intervals to assess their quality of life and to note particular complaints. The upper gastrointestinal tract was assessed endoscopically. A gastric emptying study was performed at 3, 6, and 12 months after surgery. The meal used in this dual-phase study had solid and liquid phases. For the solid phase, 74 MBq of 99mTc sulfur colloid was injected into an egg, which was then hard-boiled. For the liquid phase, 18.5 MBq of (111)In-diethyltriaminopenta acetic acid (DTPA) were mixed into 150 ml of a commercial, elentary liquid diet. RESULTS: Three months after surgery, the patients' main complaints were gastric stasis (25%), heartburn (8%) and belching (8%). The patients gradually became asymptomatic following surgery. Fifty-nine percent were asymptomatic at the 3-month follow-up, 84% at 6 months, and 92% at 12 months. There was no evidence of reflux esophagitis or gastritis after the 3-month follow-up. One patient developed a complicated duodenal ulcer. Initially, the patients all had prolonged gastric emptying of the dual phase meal, compared to normal individuals. The T1/2 for liquid meal emptying was 87+/-18 min at 3 months, 77+/-20 min at 6 months and 50+/-5 min at 1 year after surgery. The last value is the same as for healthy individuals. Solid meal emptying was still prolonged, with an emptying rate of 36+/-9.7% at 2 hours, one year after surgery. CONCLUSIONS: Segmental gastrectomy patients experienced prolonged gastric emptying in the early post-operative period. This improved in the first year after surgery. The quality of life for patients who underwent segmental gastrectomy has been reasonably good in the follow-up period to date.     

Chronic digestive loss of plasma proteins evaluated with 51Cr-albumin in Billroth I and II gastrectomized patients

The digestive clearance of albumin 51Cr was determined in patients submitted to gastrectomy due to peptic ulcer, 6 to 18 months after surgery. Patients were of both sexes, with ages varying from 24 to 70 years. Reconstruction after resection was according to Billroth I and II techniques (groups B and C). The group of control (group A) presented no digestive illness. Each group was represented by 10 individuals. The mean value and respective standard derivation for each group was respectively: Group A: 16,4 +/- 4,6; Group B: 22,0 +/- 8,1; Group C: 35,8 +/- 14,4. Comparing the mean values according to the Tukey test, significance was observed at the alpha = 0.05 level between A and C groups and B and C ones.     

Ultrasonic aspiration hepatectomy for 136 patients with hepatocellular carcinoma

AIM：To study the operativ injury,post-operative complications,the hospitalization time,the post-operative survival rate of ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device in comparison with that of conventional techniques of hepatectomy.METHODS:A total136patients with hepatocellular carcinoma(HCC,including 13patinents in 1991and 124consecutive patients from July1995to December2000)underwent ultrasonic aspiration in liver resection(groupT)and 179 HCCpatients received conventional hepatectomy during the corresponding period(groupC).The results of the two groups were compared statistically.RESULTS:There was no significant difference in the mean operation time between groupT(152&#177;11min)and C(144&#177;11min).No operation or hospital edath occurred in both groups.In groupT,the mean volumes of bleeding(463&#177;15ml)and bolld transfusion(381&#177;12ml)were markedly less than those in groupC(557&#177;20ml,and507&#177;18ml,respectively,P&lt;0.05).The mean hospitalization time of groupT(8.9&#177;0.6d)was markedly shorter than that of groupC(11.7d&#177;0.6d)(P&lt;0.05).The incidence of complications in groupTwas markedly lower than in groupC,post-operative jaundice occurred in4/136and31/179,respectively(P&lt;0.05).liver failurein0/136and2/179,cholorrhea in0/136and6/179,hydrothoraxin21/136and39/179(P&lt;0.05).ascices in9/136and2/179,cholrrheain0/136and6/179,hydrothorax in21/136and 39/179(P&lt;0.05),ascices in 9/136and 54/179,respectively(P&lt;0.05),while the 3-year survival rate of groupT(64.2%)increased markedly as compared with that of groupC(55.7%)(P&lt;0.01).CONCLUSION:The ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device could evidently reduce the operative injury and post-operative complications,shorten the hospitalization,time and prolong the survivals of HCC,patients.     

Esophageal cancer after distal gastrectomy

The effect of gastrectomy on the subsequent development of esophageal cancer was investigated. Duodenogastroesophageal reflux is thought to be common in patients after distal gastrectomy, but whether this contributes to the development of esophageal cancer in such patients is controversial. We retrospectively evaluated 153 patients who underwent subtotal esophagectomy for thoracic esophageal cancer between January 2002 and July 2005. They were divided into two groups, according to whether or not they had previously undergone a gastrectomy: group 1, comprising 14 patients who had undergone gastrectomy and group 2, comprising 139 patients who had not. Clinical profiles of the patients were obtained from the medical records and the whole resected esophagus was histopathologically examined. The interval between gastrectomy and esophagectomy in group 1 was significantly shorter in the patients who had undergone gastrectomy for gastric cancer (10.5 +/- 4.2 years) than in those who had undergone gastrectomy for a peptic ulcer (28.9 +/- 3.0 years). The interval was also somehow shorter in the patients for whom anastomosis had been performed by Billroth I (21.3 +/- 5.6 years) compared with Billroth II (29.7 +/- 3.2 years), although the difference did not reach its statistical significance (P = 0.11). Moreover, the proportion of lower third tumors in patients after gastrectomy was significantly higher compared with that of the patients with intact stomach. These findings suggest that a history of gastrectomy is associated with more lower-third squamous cell esophageal carcinoma.     

Physiopathological Heterogeneity of the Duodenal Mechanisms that Inhibit Gastric Acid Secretion in Duodenal Ulcer Patients

The effect of duodenal acidification on pentagastrin-stimulated gastric acid secretion was studied in 43 duodenal ulcer patients and in 17 normal controls. Three types of responses were observed: group A, no inhibition of gastric acid secretion occurred in 17 (40%) ulcer patients and in three (18%) controls (p less than 0.05); group B, inhibition of gastric acidity occurred in seven (16%) ulcer patients and in 12 (71%) controls (p less than 0.05), and group C, retarded gastric acid inhibition occurred in 19 (44%) duodenal ulcer patients and in 2 (12%) controls (p less than 0.05). Secretin levels did not increase after duodenal acidification, the higher percentages of failure being observed in groups A and C (p less than 0.05). The pH of the duodenal aspirate was 4.9 +/- 2 and 7.7 +/- 1.4 in ulcer patients and controls, respectively (p less than 0.05), with the low levels being detected in groups A and C (4.7 +/- 2 and 5.3 +/- 2.1) compared to group B (7.3 +/- 1.7; p less than 0.05). The results show that responses of duodenal ulcer patients to duodenal acidification are heterogeneous, and that failure of gastric secretion inhibition and defective intraduodenal acid neutralization are related.     

Post-operative chemotherapy in non-curative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: The definitive effects of post-operative chemotherapy for prolonging survival in patients with non-curative gastrectomy for advanced gastric cancer have not been established. METHODOLOGY: Eighty-three patients with advanced gastric cancer who underwent non-curative gastrectomy were divided into 49 patients with post-operative chemotherapy (chemotherapy group) and 34 patients without post-operative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-fluorouracil (5-FU) alone (n = 22), intravenous mitomycin (MMC) plus 5-FU (n = 20), intravenous methotrexate (MTX) plus 5-FU (n = 3), intravenous cisplatin plus 5-FU (n = 2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n = 2). No prior chemotherapy or radiation therapy was given. RESULTS: Although the age in the control group (mean: 71.9 years) was significantly older than in the chemotherapy group (mean: 66.1 years), there were no significant differences in the other clinical and pathological background data between the two groups. The 1-year survival rate in the chemotherapy group (71.4%) was significantly higher than in the control group (50.0%). However, the 3-year and 5-year survival rates did not significantly differ in the chemotherapy group versus the control group, 30.6% vs. 32.4% and 24.5% vs. 32.4%, respectively. Although a significant difference did not exist between the two groups, median survival after operation in the chemotherapy group (20.5 months) was longer than that in the control group (16.2 months). Furthermore, median survival of patients with peritoneal dissemination in the chemotherapy group (16.4 months) was significantly longer than that in the control group (7.7 months). CONCLUSIONS: Post-operative chemotherapy may contribute to prolonged survival in patients with non-curable advanced gastric cancer, even when patients had peritoneal dissemination. However, the long-term survival rate was not improved by post-operative chemotherapy. More aggressive chemotherapy may be needed to improve the long-term prognosis for such patients.     

Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons

BACKGROUND/AIMS: A randomized study was performed to evaluate morbidity and mortality after D2 (level 1 and 2 lymphadenectomy) and D4 (D2 plus lymphadenectomy of para-aortic lymph nodes) dissection for advanced gastric cancer. METHODOLOGY: Two hundred and fifty-six patients with advanced gastric adenocarcinoma were enrolled (128 to each group). Patients were randomly allocated into D2 (N = 128) or D4 (N = 128) group. The first and second tiers of lymph nodes are removed in D2 dissection. In D4 gastrectomy, the paraaortic lymph nodes were additionally removed. RESULTS: There was no indication of significant distribution bias with regard to age, sex, T-grade, and N-grade between the two groups. Operation time of D4 gastrectomy (369 +/- 120 min) was significantly longer than that of D2 gastrectomy (273 +/- 1103 min), and blood loss of the D4 group (872 +/- 683 mL) was significantly greater than that of the D2 group 571 +/- 527 mL (P < 0.001). Five (4%) and two (2%) medical complications developed in the D2 and D4 groups, respectively. Surgical complications developed in 28 (22%) and 48 patients (38%) after D2 and D4 gastrectomy. The most common complications were anastomotic leakage, pancreatic fistula, and abdominal abscess. Pancreatic fistula developed in 6 (19%) of 32 patients after D4 plus pancreatosplenectomy, but the incidence of pancreatic fistula after D2 gastrectomy plus pancreatosplenectomy was low (6%, 1/16). Two patients died within 30 days of operation (0.8%, 2/256), and each patient belonged to the D2 and D4 group. CONCLUSIONS: Although there is a significantly higher surgical complication rate in D4 dissection, D4 dissection can be done safely as D2 dissection when performed by well-trained surgeons.     

Clinical features and prognosis of gastric MALT lymphoma with special reference to responsiveness to H. pylori eradication and API2-MALT1 status

BACKGROUND AND AIM: Clinicopathologic characteristics and prognosis of Helicobacter pylori eradication-resistant gastric MALT lymphoma have not been well clarified. We analyzed a consecutive series of gastric MALT lymphomas at our institution regarding treatment, clinical course, and prognosis, with special reference to responsiveness to H. pylori eradication and presence of API2-MALT1. METHODS: Subjects were 92 consecutive patients with gastric MALT lymphoma. Seventy were H. pylori positive, and 87 received H. pylori eradication therapy. The remaining five cases were API2-MALT1 positive and did not receive eradication treatment. Second-line treatments were radiation therapy, total gastrectomy, and chemotherapy (rituximab, rituximab plus CHOP, or rituximab plus 2-chlorodeoxyadenosine). RESULTS: Gastric MALT lymphoma was classified into three groups, except one case with API2-MALT1 who responded to H. pylori eradication therapy: responders without API2-MALT1 (group A, N = 56, 65%), nonresponders without API2-MALT1 (group B, N = 16, 19%), and nonresponders with API2-MALT1 (group C, N = 14, 16%). Most cases in group A attained complete remission (CR) in 2 or 3 months and CR persisted for an average of 51.1 months (3-134 months). Recurrence was only seen in one case. In groups B and C, radiation therapy, chemotherapy, and total gastrectomy resulted in CR in 13, 5, and 2 cases, respectively. In 5 group B patients and 6 group C patients who did not undergo second-line therapy, disease did not progress for an average of 10.4 and 40.1 months, respectively. In 1 group C case who did not receive second-line treatment, lymphoma metastasized to the lung 12 yr after eradication. All group B patients and all but 2 group C patients remain alive; one of these deaths was from gastric carcinoma developing 7 yr after eradication. CONCLUSION: Gastric MALT lymphoma responding to H. pylori eradication demonstrated good prognosis, and for nonresponsive cases, second-line treatments resulted in CR. However, careful observation for development of gastric carcinoma and disease progression is essential during follow-up of API2-MALT1-positive MALT lymphoma when patients decline second-line treatment.     

Effect of perioperative parenteral nutritional support for gastric cancer patients undergoing gastrectomy

BACKGROUND/AIMS: Malnutrition is frequently seen in gastric cancer patients. Perioperative nutritional support may reduce postoperative complications, especially in severely depleted gastric cancer patients with GI obstruction. However, the beneficial effects of perioperative total parenteral nutrition for gastric cancer surgery patients still have not been clearly demonstrated in Taiwan. This study evaluated the effects of perioperative nutritional support for severely malnourished patients with gastric cancer undergoing gastrectomy. METHODOLOGY: The study analyzed malnourished patients with gastric cancer who underwent gastrectomy from Oct 2000 to Oct 2002. Total nutritional support was examined for severely depleted patients with body weight loss > 10% over 6 months or a low serum albumin level (< 3.0g/dL). These patients were classified into two groups, those without TPN (total parenteral nutrition) use and those with TPN use. The patients who received TPN were further divided into 2 groups, those who received TPN postoperatively and those who received it perioperatively. Correlation with the postoperative outcome was then made. RESULTS: Forty patients who underwent total gastrectomy and 78 patients who underwent subtotal gastrectomy had severe malnutrition preoperatively. We found gastric cancer patients with malnutrition had high morbidity and mortality rates (29.7% and 8.6%, respectively) when undergoing gastrectomy, especially total gastrectomy. There was a higher morbidity rate in the group without TPN (66.7% vs. 16% and 43.75% vs. 21.74%) in both the subtotal and total gastrectomy groups, and a longer postoperative stay for patients without TPN (35.21 +/- 25.05 vs. 21.32 +/- 12.32) in the total gastrectomy group than for patients with TPN in these groups. The mortality rate, morbidity rate and postoperative stay were higher in patients who received postoperative TPN only than in patients with peri-operative TPN. CONCLUSIONS: TPN use, perioperatively or postoperatively, can help reduce the morbidity and mortality of these patients. Total nutritional support is effective for patients with malnutrition undergoing gastric cancer surgery.     

Treatment of cancerous ascites and radical gastrectomy with intraperitoneal hyperthermic double-distilled water and cis-diaminodichloro-platinum perfusion

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Effect of altered gastric emptying on caffeine absorption

The effect of altered gastric emptying on caffeine absorption (tablets; 366.1 mg) was studied in patients with gastric stasis or after Billroth II partial gastrectomy with adequate gastric emptying and in healthy subjects with slowed gastric emptying due to a fibre-free and a fibre-rich liquid test meal of an elemental diet, respectively. Compared with controls (n = 15), a significantly slowed caffeine absorption was found in gastric stasis (n = 8) by means of a lower absorption rate constant KA (0.018 +/- 0.007 vs. 0.122 +/- 0.110 min-1 in controls) and a prolonged peak time tmax (160 +/- 77 vs. 46 +/- 19 min). Similar results were obtained after a fibre-free and a fibre-rich liquid test meal, respectively (n = 8 and n = 8, respectively; KA 0.035 +/- 0.01 and 0.035 +/- 0.023 min-1, respectively; tmax 91 +/- 24 and 93 +/- 23 min, respectively vs. KA 0.10 +/- 0.06 min-1 and tmax 50 +/- 14 min in controls; n = 7). After B II with adequate gastric emptying (n = 11) the absorption rate was within the normal range. The significantly lower average of the peak concentration cmax and of the area under the serum concentration-time curve x elimination rate constant (AUC x KE) in gastric stasis (5.9 +/- 1.8 micrograms/ml and 8.9 +/- 3.2 mg/l, respectively) and after B II partial gastrectomy (8.8 +/- 2.6 micrograms/ml and 10.8 +/- 3.0 mg/l, respectively) compared with controls (17.7 +/- 9.4 micrograms/ml and 20.8 +/- 10.7 mg/l respectively) probably reflect reduced bioavailability, which is apparently unchanged after a liquid test meal.     

Prokinetic effect of erythromycin after colorectal surgery

PURPOSE: Nausea and vomiting three to seven days after an elective operation on the colon and rectum remain a persistent clinical problem. Erythromycin, a safe, inexpensive drug that stimulates intestinal motilin receptors, has previously been shown to accelerate gastric emptying significantly after upper gastrointestinal surgery. We aimed to evaluate the effect of postoperative intravenous erythromycin on postoperative ileus in patients undergoing elective surgery for primary colorectal cancer. METHODS: Between May 1998 and April 1999, 150 patients undergoing primary resection of colon or rectal cancer were enrolled in this prospective, randomized, placebo-controlled trial. One hundred thirty-four patients completed the study. Patients were excluded if they had extensive metastatic disease, were taking medications known to interact with erythromycin, or if they required an ileostomy. Patients received either 200 mg of intravenous erythromycin or placebo every six hours. Clinical endpoints were recorded and continuous end-points are presented as mean +/- standard deviation. RESULTS: There were no significant complications related to erythromycin. The erythromycin (n = 65) and placebo (n = 69) groups were comparable regarding demographic and operative factors. The erythromycin group had a slightly shorter length of time to passage of flatus (4.1 +/- 1.3 vs. 4.4 +/- 1.1 days; P = 0.03). There was no significant difference between erythromycin and placebo in time to first solid food (5.6 +/- 1.9 vs. 5.4 +/- 1.8 days), time to first bowel movement (5.2 +/- 1.9 vs. 5.4 +/- 1.3 days), or time to discharge from hospital (7.5 +/- 2.0 vs. 7.6 +/- 2.8 days). There was no difference in the rate of clinically significant nausea (26 vs. 26 percent; P = 0.99), vomiting (17 vs. 16 percent; P = 0.88), or nasogastric tube placement (9 vs. 7 percent; P = 0.68). CONCLUSIONS: Erythromycin does not seem to alter clinically important outcomes related to postoperative ileus in patients undergoing resection for colorectal cancer.     

Gastric inhibitory polypeptide appears less important in mediating acid secretion.

BACKGROUND/AIMS: Gastric inhibitory polypeptide is recognized as an acid inhibitor, while its relationship with Helicobacter pylori colonization is unknown. The present study measured serum gastric inhibitory polypeptide levels in patients after various types of gastric resection and the influence of demographic characteristics including Helicobacter pylori on serum gastric inhibitory polypeptide levels. METHODOLOGY: The study included twenty patients who underwent distal gastrectomy for duodenal ulcer, 33 patients who underwent radical subtotal gastrectomy for gastric carcinoma and 7 patients who underwent total gastrectomy. Another 58 healthy subjects served as controls. Their demographic characteristics were recorded, while serum gastric inhibitory polypeptide levels were measured using a homemade radioimmunoassay kit. RESULTS: The serum gastric inhibitory polypeptide levels in the three patient groups and the controls were 246.2+/-38.7 pg/ml, 201.7+/-30.9 pg/ml, 183.5+/-34.5 pg/ml and 202.6+/-14.0 pg/ml, respectively. The difference among the four groups was not significant. Neither age, gender, body mass index, smoking, Helicobacter pylori colonization nor type of gastrectomy had an influence on serum gastric inhibitory polypeptide levels in the controls and the three patient groups. However, elapsed time since operation in patients following total gastrectomy exhibited a significant positive correlation with their gastric inhibitory polypeptide levels (r=0.89, p<0.05). CONCLUSIONS: Serum gastric inhibitory polypeptide levels remain unchanged in patients undergoing various types of gastrectomy. Colonization of Helicobacter pylori does not influence its level. This peptide is probably less important in mediating gastric acid secretion.