Long-term natural history after endoscopic resection for gastric dysplasia

Gastric conduit in patients with previous endoscopic resection of the stomach for esophageal squamous cell carcinoma

This study investigated the clinical outcomes of gastric conduits for esophageal reconstruction in esophageal squamous cell carcinoma (ESCC) patients who had previously undergone endoscopic resection of the stomach. From January 2006 to April 2023, a total of 1964 patients underwent surgery for esophageal cancer at our institution. After initially excluding 125 of these cases due to a histology other than ESCC, we identified 147 patients in the remaining population who had previously undergone a gastric endoscopic resection, among which 56 patients (67.0 ± 6.5 years) were included in the present study cohort. A gastric conduit event was defined as any new lesions at the gastric conduit. The diagnoses of a previous gastric lesion included early gastric cancer (EGC) in 32 patients (57.1%), adenoma in 23 patients (41.1%), and dysplasia in 1 (1.8%) patient. The endoscopic procedures involved an endoscopic submucosal dissection (ESD) in 36 patients (64.3%) and an endoscopic mucosal resection in 20 patients (35.7%). The 10-year event-free survival rate for the gastric conduit was 43.7%. Five patients were diagnosed with metachronous gastric neoplasm (EGC in two and adenoma in three patients). Endoscopic procedures were available for all five cases, but one patient with a metachronous EGC required a colon interposition with a total gastrectomy. In ESCC patients who have undergone an endoscopic resection of their gastric lesions, subsequent esophageal reconstruction with a gastric conduit could be a viable option if followed by regular endoscopic surveillance for the early detection and endoscopic curability of any lesions.

Gastric microbiome signature for predicting metachronous recurrence after endoscopic resection of gastric neoplasm

BACKGROUND

Changes in gastric microbiome are associated with gastric carcinogenesis. Studies on the association between gastric mucosa-associated gastric microbiome (MAM) and metachronous gastric cancer are limited. This study aimed to identify gastric MAM as a predictive factor for metachronous recurrence following endoscopic resection of gastric neoplasms.

METHOD

Microbiome analyses were conducted for 81 patients in a prospective cohort to investigate surrogate markers to predict metachronous recurrence. Gastric MAM in non-cancerous corporal biopsy specimens was evaluated using Illumina MiSeq platform targeting 16S ribosomal DNA.

RESULTS

Over a median follow-up duration of 53.8 months, 16 metachronous gastric neoplasms developed. Baseline gastric MAM varied with Helicobacter pylori infection status, but was unaffected by initial pathologic diagnosis, presence of atrophic gastritis, intestinal metaplasia, or synchronous lesions. The group with metachronous recurrence did not exhibit distinct phylogenetic diversity compared with the group devoid of recurrence but showed significant difference in β-diversity. The study population could be classified into two distinct gastrotypes based on baseline gastric MAM: gastrotype 1, Helicobacter-abundant; gastrotype 2: Akkermansia-abundant. Patients in gastrotype 2 showed higher risk of metachronous recurrence than gastrotype (Cox proportional hazard analysis, adjusted hazard ratio [95% confidence interval]: 5.10 [1.09-23.79]).

CONCLUSIONS

Gastric cancer patients can be classified into two distinct gastrotype groups by their MAM profiles, which were associated with different risk of metachronous recurrence.

Clinical outcomes of ablation of gastric dysplasia with argon plasma coagulation

BACKGROUND

Although several small cohort studies have shown the utility of argon plasma coagulation (APC) in the treatment of gastric dysplasia, its clinical significance has not been established. This study aims to assess the efficacy of APC as a first line treatment for gastric dysplasia, and identify risk factors for residual dysplasia.

METHODS

A total of 179 cases of gastric dysplasia were treated with APC and have been followed-up with upper endoscopy within 1 year. The overall incidence and the characteristics of lesions with residual dysplasia in follow-up endoscopy were analyzed by logistic regression.

RESULTS

Among 179 lesions treated with APC, 171 (95.5%) lesions have achieved complete ablation in the follow-up endoscopy. Additional APC was applied for residual dysplasia, achieving complete ablation in 97.77% (175/179). The upper third location of the gastric dysplasia was significantly associated with residual dysplasia, while tumor size, horizontal location, macroscopic morphology and grade of dysplasia showed no significant associations with residual dysplasia following the initial APC.

CONCLUSIONS

APC with meticulous follow-up can be recommended as a first line treatment in patients with gastric dysplasia.

The long-term outcomes of laparoscopic versus open pancreatoduodenectomy for ampullary carcinoma showed similar survival: a case-matched comparative study

BACKGROUND

Few studies have compared the oncological benefit of laparoscopic (LPD) and open pancreatoduodenectomy (OPD) for ampullary carcinoma. The aim of this study was to compare the oncological results of these two approaches.

METHODS

Between 2011 and 2020, 103 patients who underwent PD for ampullary carcinoma, including 31 LPD and 72 OPD, were retrospectively analyzed. Patients were matched on a 1:2 basis for age, sex, body mass index, American Society of Anaesthesiologists score, and preoperative biliary drainage. Short- and long-term outcomes of LPD and OPD were compared.

RESULTS

The 31 LPD were matched (1:2) to 62 OPD. LPD was associated with a shorter operative time (298 vs. 341 min, p = 0.02) than OPD and similar blood loss (361 vs. 341 mL, p = 0.747), but with more intra- and post-operative transfusions (29 vs. 8%, p = 0.008). There was no significant difference in postoperative mortality (6 vs. 2%), grades B/C postoperative pancreatic fistula (22 vs. 21%), delayed gastric emptying (23 vs. 35%), bleeding (22 vs. 11%), Clavien ≥ III morbidity (22 vs. 19%), or the length of hospital stay (26 vs. 21 days) between LPD and OPD, respectively, but there were more reinterventions (22 vs. 5%, p = 0.009). Pathological characteristics were similar for tumor size (21 vs. 22 mm), well differentiated tumors (41 vs. 38%), the number of harvested (23 vs. 26) or invaded lymph nodes (48 vs. 52%), R0 resection (84 vs. 90%), and other subtypes (T1/2, T3/4, phenotype). With a comparable mean follow-up (41 vs. 37 months, p = 0.59), there was no difference in 1-, 3-, and 5-year overall (p = 0.725) or recurrence-free survival (p = 0.155) which were (93, 74, 67% vs. 97, 79, 76%) and (85, 58, 58% vs. 90, 73, 73%), respectively.

CONCLUSION

This study showed a similar long-term oncological results between LPD and OPD for ampullary carcinoma. However, the higher morbidity observed with LPD compared to OPD, restricting its use to experienced centers.

The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve

BACKGROUND

In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.

METHOD

Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44).

RESULTS

In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III-IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m², and patients operated in the third period.

CONCLUSION

This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

One-stage versus two-stage management for acute cholecystitis associated with common bile duct stones: a retrospective cohort study

BACKGROUND

Both one-stage [laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE)] and two-stage [endoscopic retrograde cholangiopancreatography (ERCP) followed by sequential LC] approaches are effective treatment for concomitant common bile duct (CBD) stones and gallstone. Although many studies compared one-stage with two-stage surgical approach for cholecysto-choledocholithiasis, there are very few studies compared the two management strategies for acute cholecystitis (AC) associated with CBD stones.

METHODS

Between January 2014 and December 2019, patients with concomitant AC and CBD stones proposed to early surgery were retrospectively studied. The patients were scheduled to undergo either the one-stage [LCBDE and LC (LCBDE+LC) were undertaken at the same operation] or two-stage [preoperative ERCP for CBD stone clearance was followed by LC 1-3 days later (pre-ERCP+LC)] procedure. The success rate of complete stone clearance, procedure-related complication, hospital stay, hospitalization charges and later biliary complications were compared between the two groups.

RESULTS

Sixty patients were included in the study, 28 in the one-stage group and 32 in the two-stage group. There was no significant difference in the success rate of complete stone clearance (96.4% vs. 93.8%, P = 1.000), complication rate (10.7% vs. 9.4%, P = 1.000), incidence of pancreatitis (0 vs. 6.3%, P = 0.494) or length of hospital stay (12 ± 5 vs. 11 ± 4 days, P = 0.393) between the two groups.

CONCLUSION

For patients with concomitant AC and choledocholithiasis proposed to early surgery, both the one-stage (LCBDE+LC) and two-stage (pre-ERCP+LC) approaches were acceptable and broadly comparable in achieving clearance of CBD stones.

Minimally invasive (laparoscopic and robot-assisted) versus open approach for central pancreatectomies: a single-center experience

BACKGROUND

There continues to be an interest in minimally invasive approaches to pancreatic surgery. At our institution, there has been a progressive change from an open to minimally invasive surgery (MIS) (laparoscopic, robotic, or laparoscopic-robotic) approach for central pancreatectomies (CP). The aim of this study was to evaluate surgical outcomes with open CP (O-CP) versus minimally invasive CP (MI-CP).

METHODS

A retrospective medical review of patients who underwent CP between 1993 and 2018 at Yonsei University Health System, Seoul, Korea was performed. Short-term perioperative outcomes were compared between O-CP and MI-CP.

RESULTS

Thirty-one CPs (11 open, 20 MIS) were identified during the study period. No difference was observed in admission days between O-CP and MI-CP (21.2 vs. 16.7 days, p = 0.340), although operating time was significantly increased in the MI-CP group (296.8 vs. 374.8 min, p = 0.036). Blood loss was significantly less in MI-CP vs. O-CP (807.1 vs. 214.0 mls, p = 0.001), with no difference in post-operative new-onset diabetes (9% vs. 5%). The overall post-operative pancreatic fistula rate was 25.8%, and no significant difference between O-CP and MI-CP or complication rates (45% vs. 40%) was observed.

CONCLUSION

Despite increased operative time, MI-CP is feasible and comparable to conventional O-CP with regard to surgical outcomes in well-selected patients.

Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct

BACKGROUND

Soft pancreas with small pancreatic duct is a known risk factor for postoperative pancreatic fistula (POPF). This study demonstrated the safety and feasibility of laparoscopic duct-to-mucosa pancreaticojejunostomy (PJ) and compared perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with soft pancreas and small pancreatic duct.

METHODS

From January 2014 to December 2019, 183 patients underwent LPD and 91 patients underwent OPD by a single surgeon. Data on patients with soft pancreas and combined small pancreatic duct (≤ 2 mm) were retrospectively reviewed. Clinicopathologic characteristics, and perioperative outcomes were compared between LPD and OPD. We evaluated risk factors affecting clinically relevant POPF (CR-POPF). We also correlated calculated risks of POPF and CR-POPF between the two groups.

RESULTS

We compared 62 patients in the LPD group and 34 patients in the OPD group. Perioperative outcomes showed less blood loss, shorter hospital stays, and less postoperative pain score on postoperative day (POD)#1 and #5 in LPD compared with OPD. Postoperative complications showed no differences between LPD and OPD. LPD group showed significantly reduced CR-POPF rates compared to the OPD group (LPD 11.3% vs. OPD 29.4%, p = 0.026). Multivariate analysis identified obesity (BMI ≥ 25), thick pancreas parenchyma and open surgery as independent predicting factors for CR-POPF. The LPD group showed less CR-POPF than the OPD group according to POPF risk groups. This difference was more prominent in a high-risk group.

CONCLUSION

With appropriate laparoscopic technique, LPD is feasible and safe and reduces CR-POPF in soft pancreas with a small pancreatic duct.

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.