Vagus nerve preservation selectively restores visceral fat volume in patients with early gastric cancer who underwent gastrectomy. J Surg Res. 2012;173:60-67. [PMID: 21035138 DOI: 10.1016/j.jss.2010.08.040]

Clinical comparison of total gastrectomy with single-vessel transection Roux-en-Y reconstruction vs total gastrectomy with conventional Roux-en-Y reconstruction for proximal gastric cancer

PURPOSE

This study aimed to investigate the clinical benefits of single-vessel transection Roux-en-Y (SR-Y) reconstruction after total gastrectomy.

METHODS

A total of 194 patients with proximal gastric cancer were prospectively recruited at Fudan University Shanghai Cancer Center between January 2021 and September 2022. This study included 97 patients who underwent conventional Roux-en-Y reconstruction and 97 patients who underwent SR-Y reconstruction. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were compared between the conventional and single-vessel transection groups.

RESULTS

There were no significant differences in baseline characteristics between the 2 groups in terms of age (P = .882), gender (P = .595), body mass index (P = .683), tumor location (P = .568), TNM stage (P = .122), tumor size (P = .927), anemia (P = .756), neoadjuvant chemotherapy (P = .730), and surgical approach (P = .592). However, compared with the conventional group, the single-vessel transection group had a shorter operation time (162.5 ± 37.6 vs 178.5 ± 48.3 min, respectively; P = .011) and less intraoperative bleeding (167.2 ± 91.8 vs 207.8 ± 167.5 mL, respectively; P = .037) after complete reservation of the terminal jejunal vascular arches. Nevertheless, there were no significant differences in tensions in the jejunal mesentery, durations of peritoneal drainage, postoperative hospital stay durations, the number of lymph node dissections, and early complications between the 2 groups.

CONCLUSION

SR-Y reconstruction can simplify surgical procedures, reduce operating time, and minimize intraoperative bleeding without increasing tensions in the jejunal mesentery or short-term complications. It is feasible and safe and worth further promotion in clinical practice.

Fasting pancreatic polypeptide predicts incident microvascular and macrovascular complications of type 2 diabetes: An observational study

AIMS

Pancreatic polypeptide (PP) is elevated in people with vascular risk factors such as type 2 diabetes or increased visceral fat. We investigated potential relationships between PP and microvascular and macrovascular complications of diabetes.

MATERIALS AND METHODS

Animal study: Subcutaneous PP infusion for 4 weeks in high fat diet mouse model. Retinal mRNA submitted for Ingenuity Pathway Analysis. Human study: fasting PP measured in 1478 participants and vascular complications recorded over median 5.5 (IQR 4.9-5.8) years follow-up.

RESULTS

Animal study: The retinal transcriptional response to PP was indicative of cellular stress and damage, and this footprint matched responses described in previously published studies of retinal disease. Of mechanistic importance the transcriptional landscape was consistent with upregulation of folliculin, a recently identified susceptibility gene for diabetic retinopathy. Human study: Adjusting for established risk factors, PP was associated with prevalent and incident clinically significant retinopathy (odds ratio (OR) 1.289 (1.107-1.501) p = 0.001; hazard ratio (HR) 1.259 (1.035-1.531) p = 0.0213), albuminuria (OR 1.277 (1.124-1.454), p = 0.0002; HR 1.608 (1.208-2.141) p = 0.0011), and macrovascular disease (OR 1.021 (1.006-1.037) p = 0.0068; HR 1.324 (1.089-1.61), p = 0.0049), in individuals with type 2 diabetes, and progression to diabetes in non-diabetic individuals (HR 1.402 (1.081-1.818), p = 0.0109).

CONCLUSIONS

Elevated fasting PP is independently associated with vascular complications of diabetes and affects retinal pathways potentially influencing retinal neuronal survival. Our results suggest possible new roles for PP-fold peptides in the pathophysiology of diabetes complications and vascular risk stratification.

Preservation of the celiac branch of the vagus nerve reduces the incidence of postoperative diarrhea in gastric cancer: a cohort study

BACKGROUND

To investigate the short-term and long-term outcomes of preserving the celiac branch of the vagus nerve during laparoscopic distal gastrectomy.

METHODS

A total of 149 patients with prospective diagnosis of gastric cancer who underwent laparoscopic-assisted distal gastrectomy (LADG) combined with Billroth-II anastomosis and D2 lymph node dissection between 2017 and 2018 were retrospectively analyzed. The patients were divided into the preserved LADG group (P-LADG, n = 56) and the resected LADG group (R-LADG, n = 93) according to whether the vagus nerve celiac branch was preserved. We selected 56 patients (P-LADG, n = 56) with preservation of the celiac branch of the vagus nerve and 56 patients (R-LADG, n = 56) with removal of the celiac branch of the vagus nerve by propensity-matched score method. Postoperative nutritional status, weight change, short-term and long-term postoperative complications, and gallstone formation were evaluated in both groups at 5 years of postoperative follow-up. The status of residual gastritis and bile reflux was assessed endoscopically at 12 months postoperatively.

RESULTS

The incidence of diarrhea at 5 years postoperatively was lower in the P-LADG group than in the R-LADG group (p < 0.05). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 3.389, 95% confidential interval = 1.143-10.049, p = 0.028). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 4.371, 95% confidential interval = 1.418-13.479, p = 0.010).

CONCLUSIONS

Preservation of the celiac branch of the vagus nerve in LADG reduced the incidence of postoperative diarrhea postoperatively in gastric cancer.

TRIAL REGISTRATION

This study was registered with the Ethics Committee of the First Affiliated Hospital of Dalian Medical University in 2014 under the registration number: LCKY2014-04(X).

Association of visceral adipose tissue with postoperative outcome in upper gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

There is no consensus on the relation between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer.

OBJECTIVES

The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the WHO International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through 20 July 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using the Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. HRs and 95% CIs for OS were pooled.

RESULTS

Ninety-one studies (n = 20,583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relation between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (HR: 0.69; 95% CI: 0.55, 0.87; I2 = 65%; n = 3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias, and publication bias.

CONCLUSIONS

High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

The Vagus Nerve and Spleen: Influence on White Adipose Mass and Histology of Obese and Non-obese Rats

The vagus nerve (VN) and spleen represent a complex interface between neural and immunological functions, affecting both energy metabolism and white adipose tissue (WAT) content. Here, we evaluated whether vagal and splenic axis participates in WAT mass regulation in obese and non-obese male Wistar rats. High doses of monosodium glutamate (M; 4 g/Kg) were administered during the neonatal period to induce hypothalamic lesion and obesity (M-Obese rats). Non-obese or Control (CTL) rats received equimolar saline. At 60 days of life, M-Obese and CTL rats were randomly distributed into experimental subgroups according to the following surgical procedures: sham, subdiaphragmatic vagotomy (SV), splenectomy (SPL), and SV + SPL (n = 11 rats/group). At 150 days of life and after 12 h of fasting, rats were euthanized, blood was collected, and the plasma levels of glucose, triglycerides, cholesterol, insulin, and interleukin 10 (IL10) were analyzed. The visceral and subcutaneous WAT depots were excised, weighed, and histologically evaluated for number and size of adipocytes as well as IL10 protein expression. M-Obese rats showed higher adiposity, hyperinsulinemia, hypertriglyceridemia, and insulin resistance when compared with CTL groups (p < 0.05). In CTL and M-Obese rats, SV reduced body weight gain and triglycerides levels, diminishing adipocyte size without changes in IL10 expression in WAT (p< 0.05). The SV procedure resulted in high IL10 plasma levels in CTL rats, but not in the M-Obese group. The splenectomy prevented the SV anti-adiposity effects, as well as blocked the elevation of IL10 levels in plasma of CTL rats. In contrast, neither SV nor SPL surgeries modified the plasma levels of IL10 and IL10 protein expression in WAT from M-Obese rats. In conclusion, vagotomy promotes body weight and adiposity reduction, elevating IL10 plasma levels in non-obese animals, in a spleen-dependent manner. Under hypothalamic obesity conditions, VN ablation also reduces body weight gain and adiposity, improving insulin sensitivity without changes in IL10 protein expression in WAT or IL10 plasma levels, in a spleen-independent manner. Our findings indicate that the vagal-spleen axis influence the WAT mass in a health state, while this mechanism seems to be disturbed in hypothalamic obese animals.

Easy fixation effects the prevention of Peterson’s hernia and Roux stasis syndrome

BACKGROUND

Laparoscopic distal gastrectomy (LDG) for gastric cancer has been progressed and popular in Japan, since it was first described in 1994. Several reconstruction methods can be adopted according to remnant stomach size, and balance of pros and cons. Roux-en-Y (R-Y) reconstruction is a one of standard options after LDG. Its complications include Petersen’s hernia and Roux stasis syndrome. Here we report our ingenious attempt, fixation of Roux limb and duodenal stump, for decreasing the development of Petersen’s hernia and Roux stasis syndrome.

AIM

To develop a method to decrease the development of Petersen’s hernia and Roux stasis syndrome.

METHODS

We performed ante-colic R-Y reconstruction after LDG. After R-Y reconstruction, we fixed Roux limb onto the duodenal stump in a smooth radian. Via this small improvement in Roux limb, Roux limb was placed to the right of the ligament of Treitz. This not only changed the anatomy of the Petersen’s defect, but it also kept a fluent direction of gastrointestinal anastomosis and avoided a cross-angle after jejunojejunostomy. 31 patients with gastric cancer was performed this technique after R-Y reconstruction. Clinical parameters including clinicopathologic characteristics, perioperative outcomes, postoperative complication and follow-up data were evaluated.

RESULTS

The operative time was (308.0 ± 84.6 min). This improvement method took about 10 min. Two (6.5%) patients experienced pneumonia and pancreatitis, respectively. No patient required reoperation or readmission. All patients were followed up for at least 3 year, and none of the patients developed postoperative complications related to internal hernia or Roux stasis syndrome.

CONCLUSION

This 10 min technique is a very effective method to decrease the development of Petersen’s hernia and Roux stasis syndrome in patients who undergo LDG.

A Brain-Melanocortin-Vagus Axis Mediates Adipose Tissue Expansion Independently of Energy Intake

The melanocortin system is a brain circuit that influences energy balance by regulating energy intake and expenditure. In addition, the brain-melanocortin system controls adipose tissue metabolism to optimize fuel mobilization and storage. Specifically, increased brain-melanocortin signaling or negative energy balance promotes lipid mobilization by increasing sympathetic nervous system input to adipose tissue. In contrast, calorie-independent mechanisms favoring energy storage are less understood. Here, we demonstrate that reduction of brain-melanocortin signaling actively promotes fat mass gain by activating the lipogenic program and adipocyte and endothelial cell proliferation in white fat depots independently of caloric intake via efferent nerve fibers conveyed by the common hepatic branch of the vagus nerve. Those vagally regulated obesogenic signals also contribute to the fat mass gain following chronic high-fat diet feeding. These data reveal a physiological mechanism whereby the brain controls energy stores that may contribute to increased susceptibility to obesity.

Brain-melanocortin signaling controls fat mass indirectly by regulating energy balance and by direct control of lipid mobilization from adipose tissue via sympathetic nervous system activity. Holland et al. show that reduced brain-melanocortin signaling promotes white adipose tissue expansion via signals conveyed by efferent innervation of the vagus nerve.

Comparison of Postoperative Nutritional Status after Distal Gastrectomy for Gastric Cancer Using Three Reconstructive Methods: a Multicenter Study of over 1300 Patients

PURPOSE

Perioperative nutritional status has been reported to be associated with short- and long-term outcomes after surgery in gastric cancer patients. This study compared changes in nutritional status after distal gastrectomy using the Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY) reconstruction techniques in gastric cancer patients.

MATERIALS AND METHODS

Data from 1305 gastric cancer patients who underwent distal gastrectomy at two tertiary hospitals from January 2011 to December 2016 were reviewed. The patients were divided into three groups according to reconstruction type: BI, BII, and RY. We evaluated changes in nutritional parameters including body mass index (BMI), biochemical data, the prognostic nutritional index (PNI), nutritional risk index (NRI), and geriatric nutritional risk index (GNRI) preoperatively, and 3, 6, and 12 months after surgery.

RESULTS

Total protein, albumin, PNI, and NRI were significantly lower in the BII group than in the BI and RY groups during follow-up (P < 0.001). In multivariate analysis, reconstruction types were independently related to decreases in BMI (> 10%), low serum protein, albumin, and cholesterol 12 months after surgery. Compared with BI, BII was associated with decreased BMI, low protein, and albumin and RY was associated with decreased BMI and low cholesterol.

CONCLUSION

During the first year after gastric cancer surgery, postoperative nutritional status differed according to the reconstruction type; BI resulted in the least weight and nutritional loss, RY yielded results comparable with BI in the nutritional indexes, and BII resulted in the greatest nutritional loss.

Obesity is a risk factor for internal hernia after laparoscopic or robot-assisted gastrectomy with mesenteric defect closure for gastric cancer

BACKGROUND

Internal hernia (IH) is a life-threatening complication after gastrectomy. The increase in the frequency of minimally invasive surgery is considered to be related to the increase in the frequency of IH, and mesenteric defect closure has been recommended to reduce this complication. However, IH can occur even when mesenteric defects are closed, so the risk of IH in the patients with mesenteric closure remains uncertain. We attempted to clarify the risk factors for IH in these patients.

METHODS

From 2013 to 2017, we retrospectively reviewed 310 patients with gastric cancer who underwent laparoscopic or robot-assisted gastrectomy with Roux-en-Y (RY) or double-tract (DT) reconstruction with mesenteric defect closure. Univariate and multivariate analyses were performed to identify the risk factors.

RESULTS

The incidence of IH was 1.3% (n = 4). A preoperative body mass index (BMI) ≥ 25 kg/m² (p = 0.044), postoperative chemotherapy (p = 0.034), and body weight loss rate at 6 months ≥ 15% (p = 0.045) were risk factors for IH on a univariate analysis. A multivariate analysis showed that a BMI at the time of surgery of ≥ 25 kg/m² was an independent risk factor for IH (odds ratio = 11.9, p = 0.049).

CONCLUSIONS

Preoperative obesity is an independent risk factor for IH after minimally invasive gastrectomy followed by RY or DT reconstruction with mesenteric defect closure. We need to conduct vigilant follow-up for IH, especially in these patients.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy

Purpose

The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy.

Materials and Methods

Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10–30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively.

Results

Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed.

Conclusions

Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients.

Trial Registration

Clinical Research Information Service Identifier: KCT0000823

Internal hernia after proximal gastrectomy with jejunal interposition

Although internal hernia (IH) has been reported after laparoscopic distal or total gastrectomy with Roux-en-Y reconstruction, there are few reports of IH after proximal gastrectomy with jejunal interposition (PG-JI). The aim of this study was to analyze the incidence and clinical features of IH after PG-JI. This study retrospectively reviewed 71 patients who underwent PG-JI for gastric cancer at a single institution between July 2007 and December 2016. The median follow-up period after PG-JI was 50 months. Four patients (5.6%) developed IH. IH occurred in 3 of 38 patients after open PG (7.9%) and 1 of 33 after laparoscopic PG (3.1%; p = 0.38). The site of IH was Petersen in all cases, where the Petersen defect was not closed. All patients had abdominal pain at onset, and the CT revealed a whirl sign. Bowel resection was required in three patients (75%). There was no morbidity. IH after PG-JI occurred regardless of operative approach (open or laparoscopic). A high degree of suspicion for IH should be maintained in patients after gastrectomy with abdominal pain and a whirl sign on CT. Closure of the mesenteric defects should be considered to reduce the incidence of IH after surgery.

Prostate cancer in East Asia: evolving trend over the last decade

Prostate cancer is now becoming an emerging health priority in East Asia. Most of our current knowledge on Prostate cancer has been generated from studies conducted in Western population; however, there is considerable heterogeneity of Prostate cancer between East and West. In this article, we reviewed epidemiologic trends, risk factors, disease characteristics and management of Prostate cancer in East Asian population over the last decade. Growing evidence from East Asia suggests an important role of genetic and environmental risk factors interactions in the carcinogenesis of Prostate cancer. Exposure to westernized diet and life style and improvement in health care in combination contribute substantially to the increasing epidemic in this region. Diagnostic and treatment guidelines in East Asia are largely based on Western knowledge. Although there is a remarkable improvement in the outcome over the last decade, ample evidence suggests an inneglectable difference in diagnostic accuracy, treatment efficacy and adverse events between different populations. The knowledge from western countries should be calibrated in the Asian setting to provide a better race-based treatment approach. In this review, we intend to reveal the evolving trend of Prostate cancer in the last decade, in order to gain evidence to improve Prostate cancer prevention and control in East Asia.

Skeletal muscle loss after total gastrectomy, exacerbated by adjuvant chemotherapy

BACKGROUND

Skeletal muscle loss is associated with physical disability, nosocomial infections, postoperative complications, and decreased survival. Preventing the loss of skeletal muscle mass after gastrectomy may lead to improved outcomes. The aims of this study were to assess changes in skeletal muscle mass after total gastrectomy (TG) and to clarify the clinical factors affecting significant loss of skeletal muscle after TG.

PATIENTS AND METHODS

One hundred and two patients undergoing TG for primary gastric cancer underwent abdominal computed tomography before and 1 year after TG to precisely quantify postoperative changes in skeletal muscle and adipose tissue. Univariate and multivariate logistic regression analyses identified clinical factors contributing to significant loss of skeletal muscle after TG.

RESULTS

At 1 year after TG, the mass of both skeletal muscle and adipose tissue was reduced by 6.20 ± 6.80 and 65.8 ± 36.1% of the preoperative values, respectively, and 26 patients (25.5%) showed a significant loss of skeletal muscle of more than 10%. Adjuvant chemotherapy with S-1 for ≥6 months (hazard ratio 26.61, 95% confidence interval, 3.487-203.1) was identified as the single independent risk factor for a significant loss of skeletal muscle.

CONCLUSIONS

Skeletal muscle loss was exacerbated by extended adjuvant chemotherapy after TG. Further research should identify appropriate nutritional interventions for maintaining skeletal muscle mass and leading to improved outcomes.

Effect of vagotomy during Roux-en-Y gastric bypass surgery on weight loss outcomes

BACKGROUND

During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB.

METHODS

We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy.

RESULTS

Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models.

CONCLUSION

Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Vagal hyperactivity due to ventromedial hypothalamic lesions increases adiponectin production and release

In obese humans and animals, adiponectin production and release in adipose tissue are downregulated by feedback inhibition, resulting in decreased serum adiponectin. We investigated adiponectin production and release in ventromedial hypothalamic (VMH)-lesioned animals. VMH-lesioned mice showed significant increases in food intake and body weight gain, with hyperinsulinemia and hyperleptinemia at 1 and 4 weeks after VMH-lesioning. Serum adiponectin was elevated in VMH-lesioned mice at 1 and 4 weeks, despite adipocyte hypertrophy in subcutaneous and visceral adipose tissues and increased body fat. Adiponectin production and mRNA were also increased in both adipose tissues in VMH-lesioned mice at 1 week. These results were replicated in VMH-lesioned rats at 1 week. Daily atropine administration for 5 days or subdiaphragmatic vagotomy completely reversed the body weight gain and eliminated the increased adiponectin production and release in these rats, with reversal to a normal serum adiponectin level. Parasympathetic nerve activation by carbachol infusion for 5 days in rats increased serum adiponectin, with increased adiponectin production in visceral and subcutaneous adipose tissues without changes of body weight. These results demonstrate that activation of the parasympathetic nerve by VMH lesions stimulates production of adiponectin in visceral and subcutaneous adipose tissues and adiponectin release, resulting in elevated serum adiponectin.

Laparoscopy-assisted pylorus-preserving gastrectomy is better than laparoscopy-assisted distal gastrectomy for middle-third early gastric cancer

OBJECTIVE

The purpose of this study is to compare the surgical, oncologic safety and the nutritional, functional benefit of laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy (LADG) for middle-third early gastric cancers (EGC).

BACKGROUND

Of those patients with middle-third EGC, it is still difficult to determine which procedure is better between LADG and LAPPG despite alleged advantages of LAPPG.

METHODS

For middle-third EGC, a retrospective analysis was performed comparing those who underwent LADG and those who underwent LAPPG. To evaluate surgical and oncologic safety, clinicopathologic differences including the postoperative morbidity, the pattern of lymph node metastasis and recurrence were analyzed. Postoperative protein, albumin, quantification of abdominal fat area using abdomen computed tomography, and the incidence of postoperative gallstone were compared for the evaluation of functional advantages.

RESULTS

The overall postoperative morbidity rate was similar between LADG (n = 176) and LAPPG (n = 116). Delayed gastric emptying was less frequent in LADG than in LAPPG (1.7% vs 7.8%); however, the rates of all the other complications were significantly higher in LADG than in LAPPG (17.0% vs 7.8%). The number of examined lymph nodes and metastatic lymph nodes at each lymph node station was not significantly different and 3-year recurrence-free survival rates were also similar between LADG and LAPPG (98.8% vs 98.2%). Decreases in serum protein and albumin in postoperative 1 to 6 months and abdominal fat area in postoperative 1 year were significantly greater in LADG than in LAPPG. The 3-year cumulative incidence of gallstone was significantly higher in LADG than in LAPPG (6.5% vs 0.0%).

CONCLUSIONS

For middle-third EGC, LAPPG can be considered as a better treatment option than LADG in terms of nutritional advantage and lower incidence of gallstone.

Petersen's hernia after laparoscopic distal gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND

To decrease the incidence of internal hernia after laparoscopic Roux-en-Y gastric bypass, recent recommendations indicated closure of mesenteric defects and Petersen's defect. Laparoscopic distal gastrectomy for gastric cancer is used increasingly, so the incidence of Petersen's hernia can also increase, but the trend has not been studied.

METHODS

This study retrospectively reviewed 358 consecutive patients who underwent laparoscopic distal gastrectomy for gastric cancer at one institution, with antecolic Roux-en-Y (RY) reconstruction.

RESULTS

Petersen's hernia occurred in 6 (2.2 %) of 268 patients whose Petersen's defect was not closed by a mean of 351 days after surgery. All the patients underwent reoperation with reduction and repair of the hernia except the first case. In 90 subsequent cases, with closure of the Petersen's defect, internal hernias did not occur (0/90 cases; p = 0.06). Focusing on the totally laparoscopic procedure, Petersen's hernia occurred in 2 (5.1 %) of 39 patients, whereas in 81 subsequent cases, with closure of Petersen's defect, internal hernias did not occur (0/81 cases; p = 0.03).

CONCLUSIONS

Based on the recent recommendations for bariatric surgery, closure of this potential hernia defect is necessary after laparoscopic distal gastrectomy with R-Y reconstruction for gastric cancer.

Visceral fat changes after distal gastrectomy according to type of reconstruction procedure for gastric cancer

BACKGROUND

Noncancerous causes of death, such as cerebrovascular or cardiac disease, are not rare in patients with gastric cancer who had undergone curative gastrectomy. Metabolic syndrome, characterized by visceral fat accumulation, is a risk factor for cerebrovascular and cardiac diseases. However, there is limited information on the effects of reconstruction procedures on changes in visceral fat after distal gastrectomy. The aim of this study was to analyze the impact of the reconstruction procedure (Roux-en-Y reconstruction (RY) and Billroth I reconstruction (BI)) on changes in visceral fat, as determined using computed tomography.

METHODS

The study subjects were 152 patients with gastric cancer who underwent distal gastrectomy with lymphadenectomy between 2002 and 2007. The visceral fat area was measured for one cross-sectional computed tomogram obtained at the level of the umbilicus.

RESULTS

Adjuvant chemotherapy (yes vs. no, P = 0.0006), type of reconstruction (BI vs. RY, P = 0.0146), field of lymph node dissection (<D2 vs. ≥D2, P = 0.0020), omentectomy (yes vs. no, P = 0.0003), and pathological stage (1/2 vs. 3/4; P = 0.0023) correlated significantly with postoperative visceral fat loss. Multivariate logistic regression analysis identified reconstruction (BI vs. RY; P = 0.0232) and adjuvant chemotherapy (yes vs. no, P = 0.0330) as the significant determinants of visceral fat loss after surgery.

CONCLUSIONS

Visceral fat loss after RY was larger than that after BI. Further prospective studies are needed to confirm the effects of reconstruction after distal gastrectomy on visceral fat.

Evaluation of electrical activity after vagus nerve-preserving distal gastrectomy using multichannel electrogastrography

BACKGROUND

Multichannel electrogastrography (M-EGG) can be used to evaluate gastrointestinal motility. The myoelectric activity of the remnant stomach after surgery has not been measured by M-EGG. This study examined whether myoelectric activity varied with surgical technique and compared vagus nerve-preserving distal gastrectomy (VP-DG) with standard distal gastrectomy without vagus nerve preservation (DG). Furthermore, we examined the relationship between the M-EGG findings and patients' postoperative symptoms.

METHODS

Twenty-six patients who underwent VP-DG, 20 who underwent DG, and 12 healthy volunteers as controls were examined with M-EGG. The Gastrointestinal Symptom Rating Scale (GSRS) was used to assess postoperative symptoms.

RESULTS

Longer periods of normal gastric function (normogastria, 2.0-4.0 cycle min(-1)) were detected in channel 1 in the VP-DG group than in the DG group in either the fasted or fed state (P<0.05). The percentage of slow wave coupling (%SWC) in the fed state correlated negatively with GSRS scores (reflux, r=-0.59, P=0.02; abdominal pain, r=-0.51, P=0.04, indigestion, r=-0.59, P=0.02 and total score, r=-0.75, P=0.02).

CONCLUSIONS

Slow waves can be recorded non-invasively using M-EGG in the remnant stomach following gastrectomy. The VP-DG group showed better preserved gastric myoelectric activity than the DG group, and the %SWC showed a significant negative correlation with scores of GSRS (reflux, abdominal pain, indigestion and total score) in the VP-DG group.

Recent trend of internal hernia occurrence after gastrectomy for gastric cancer

BACKGROUND

The incidence of internal hernia after gastrectomy can increase with the increasing use of laparoscopic surgery, although this trend has not been elucidated.

METHODS

Clinical information was collected from medical records and by questionnaire for 18 patients who underwent surgical treatment for internal hernia after gastrectomy for gastric cancer in 24 hospitals from January 2005 to December 2009.

RESULTS

Gastrectomy for gastric cancer was open/distal gastrectomy (DG) in five (28%) patients, open/total gastrectomy (TG) in seven (39%), laparoscopy-assisted/DG in three (17%), and laparoscopy-assisted/TG in 3 (17%). Reconstruction was by Roux-Y methods in all patients. The hernia orifice was classified as a jejunojejunostomy mesenteric defect in eight patients (44%), dorsum of the Roux limb (Petersen's space) in eight (44%), and one (5%) each of esophageal hiatus and mesenterium of the transverse colon. Among 8,983 patients who underwent gastrectomy for gastric cancer, a postoperative survey revealed that 13 patients underwent surgical treatment for internal hernia in the same hospitals. The 3-year incidence rate of the internal hernia was 0.19%, which was significantly higher after laparoscopy-assisted than open gastrectomy (0.53 vs. 0.15%, p = 0.03). Patients with an internal hernia had a mean (±SD) low weight at hernia operation (body mass index 17.9 ± 1.6 kg/m(2)) and marked weight loss after gastrectomy (weight reduction 15.6 ± 5.8%).

CONCLUSIONS

Gastrectomy with Roux-Y reconstruction for gastric cancer leaves several spaces that can cause internal hernia formation. Laparoscopic surgery and postoperative body weight loss are potential risk factors.

Effects of vagus nerve preservation and vagotomy on peptide YY and body weight after subtotal gastrectomy

AIM: To investigate the relationship between the function of vagus nerve and peptide YY_3-36 and ghrelin levels after subtotal gastrectomy.

METHODS: We enrolled a total of 16 patients who underwent subtotal gastrectomy due to gastric cancer. All surgeries were performed by a single skilled surgeon. We measured peptide YY_3-36, ghrelin, leptin, insulin, growth hormone levels, and body weight immediately before and one month after surgery.

RESULTS: Vagus nerve preservation group showed less body weight loss and less increase of peptide YY_3-36 compared with vagotomy group (-5.56 ± 2.24 kg vs -7.85 ± 1.57 kg, P = 0.037 and 0.06 ± 0.08 ng/mL vs 0.19 ± 0.12 ng/mL, P = 0.021, respectively). Moreover, patients with body weight loss of less than 10% exhibited reduced elevation of peptide YY_3-36 level, typically less than 20% [6 (66.7%) vs 0 (0.0%), P = 0.011, odd ratio = 3.333, 95% confidence interval (1.293, 8.591)].

CONCLUSION: Vagus nerve preservation contributes to the maintenance of body weight after gastrectomy, and this phenomenon may be related to the suppressed activity of peptide YY_3-36.