Short-term outcomes of laparoscopic and robotic distal gastrectomy for gastric cancer: Real-world evidence from a large-scale inpatient database in Japan

BACKGROUND AND OBJECTIVES

Robotic distal gastrectomy (RDG) has been widely performed throughout Japan since it became insured in 2018. This study aimed to evaluate the short-term outcomes of RDG and laparoscopic distal gastrectomy (LDG) for gastric cancer using real-world data.

METHODS

A total of 4161 patients who underwent LDG (n = 3173) or RDG (n = 988) for gastric cancer between April 2018 and October 2022 were identified through the Japanese Diagnosis Procedure Combination Database, which covers 42 national university hospitals. The primary outcome was postoperative in-hospital mortality rate. The secondary outcomes were postoperative complication rates, time to diet resumption, and postoperative length of stay (LOS).

RESULTS

In-hospital mortality and postoperative complication rates in the RDG group were comparable with those in the LDG group (0.1% vs. 0.0%, p = 1.000, and 8.7% vs. 8.2%, p = 0.693, respectively). RDG was associated with a longer duration of anesthesia (325 vs. 262 min, p < 0.001), similar time to diet resumption (3 vs. 3 days, p < 0.001), and shorter postoperative LOS (10 vs. 11 days, p < 0.001) compared with LDG.

CONCLUSIONS

RDG was performed safely and provided shorter postoperative LOS, since it became covered by insurance in Japan.

Uncut Roux-en-Y reconstruction after distal gastrectomy for gastric cancer

BACKGROUND

Choosing an optimal reconstruction method is pivotal for patients with gastric cancer undergoing distal gastrectomy. The uncut Roux-en-Y reconstruction, a variant of the conventional Roux-en-Y approach (or variant of the Billroth II reconstruction), employs uncut devices to occlude the afferent loop of the jejunum. This modification is designed to mitigate postgastrectomy syndrome and enhance long-term functional outcomes. However, the comparative benefits and potential harms of this approach compared to other reconstruction techniques remain a topic of debate.

OBJECTIVES

To assess the benefits and harms of uncut Roux-en-Y reconstruction after distal gastrectomy in patients with gastric cancer.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, WanFang Data, China National Knowledge Infrastructure, and clinical trial registries for published and unpublished trials up to November 2023. We also manually reviewed references from relevant systematic reviews identified by our search. We did not impose any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing uncut Roux-en-Y reconstruction versus other reconstructions after distal gastrectomy for gastric cancer. The comparison groups encompassed other reconstructions such as Billroth I, Billroth II (with or without Braun anastomosis), and Roux-en-Y reconstruction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The critical outcomes included health-related quality of life at least six months after surgery, major postoperative complications within 30 days after surgery according to the Clavien-Dindo Classification (grades III to V), anastomotic leakage within 30 days, changes in body weight (kg) at least six months after surgery, and incidence of bile reflux, remnant gastritis, and oesophagitis at least six months after surgery. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We identified eight trials, including 1167 participants, which contributed data to our meta-analyses. These trials were exclusively conducted in East Asian countries, predominantly in China. The studies varied in the types of uncut devices used, ranging from 2- to 6-row linear staplers to suture lines. The follow-up periods for long-term outcomes spanned from 3 months to 42 months, with most studies focusing on a 6- to 12-month range. We rated the certainty of evidence from low to very low. Uncut Roux-en-Y reconstruction versus Billroth II reconstruction In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to major postoperative complications (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.24 to 4.05; I² = 0%; risk difference (RD) 0.00, 95% CI -0.04 to 0.04; I² = 0%; 2 studies, 282 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.64, 95% CI 0.29 to 1.44; I² not applicable; RD -0.00, 95% CI -0.03 to 0.02; I² = 32%; 3 studies, 615 participants; very low-certainty evidence). We are very uncertain about these results. Focusing on long-term outcomes, low- to very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to changes in body weight (mean difference (MD) 0.04 kg, 95% CI -0.84 to 0.92 kg; I² = 0%; 2 studies, 233 participants; low-certainty evidence), may reduce the incidence of bile reflux into the remnant stomach (RR 0.67, 95% CI 0.55 to 0.83; RD -0.29, 95% CI -0.43 to -0.16; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 3 to 7; 1 study, 141 participants; low-certainty evidence), and may have little or no effect on the incidence of remnant gastritis (RR 0.27, 95% CI 0.01 to 5.06; I2 = 78%; RD -0.15, 95% CI -0.23 to -0.07; I2 = 0%; NNTB 7, 95% CI 5 to 15; 2 studies, 265 participants; very low-certainty evidence). No studies reported on quality of life or the incidence of oesophagitis. Uncut Roux-en-Y reconstruction versus Roux-en-Y reconstruction In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may make little to no difference to major postoperative complications (RR 4.74, 95% CI 0.23 to 97.08; I² not applicable; RD 0.01, 95% CI -0.02 to 0.04; I² = 0%; 2 studies, 256 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.34, 95% CI 0.05 to 2.08; I² = 0%; RD -0.02, 95% CI -0.06 to 0.02; I² = 0%; 2 studies, 213 participants; very low-certainty evidence). We are very uncertain about these results. Focusing on long-term outcomes, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may increase the incidence of bile reflux into the remnant stomach (RR 10.74, 95% CI 3.52 to 32.76; RD 0.57, 95% CI 0.43 to 0.71; NNT for an additional harmful outcome (NNTH) 2, 95% CI 2 to 3; 1 study, 108 participants; very low-certainty evidence) and may make little to no difference to the incidence of remnant gastritis (RR 1.18, 95% CI 0.69 to 2.01; I² = 60%; RD 0.03, 95% CI -0.03 to 0.08; I² = 0%; 3 studies, 361 participants; very low-certainty evidence) and incidence of oesophagitis (RR 0.82, 95% CI 0.53 to 1.26; I² = 0%; RD -0.02, 95% CI -0.07 to 0.03; I² = 0%; 3 studies, 361 participants; very low-certainty evidence). We are very uncertain about these results. Data were insufficient to assess the impact on quality of life and changes in body weight.

AUTHORS' CONCLUSIONS

Given the predominance of low- to very low-certainty evidence, this Cochrane review faces challenges in providing definitive clinical guidance. We found the majority of critical outcomes may be comparable between the uncut Roux-en-Y reconstruction and other methods, but we are very uncertain about most of these results. Nevertheless, it indicates that uncut Roux-en-Y reconstruction may reduce the incidence of bile reflux compared to Billroth-II reconstruction, albeit with low certainty. In contrast, compared to Roux-en-Y reconstruction, uncut Roux-en-Y may increase bile reflux incidence, based on very low-certainty evidence. To strengthen the evidence base, further rigorous and long-term trials are needed. Additionally, these studies should explore variations in surgical procedures, particularly regarding uncut devices and methods to prevent recanalisation. Future research may potentially alter the conclusions of this review.

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

Outcomes of endoscopic ultrasound-guided gastro-enterostomy for gastric outlet obstruction in a two-centre Australian Cohort (with video)

PURPOSE

Endoscopic ultrasound-guided gastro-enterostomy (EUS-GE) is a relatively novel technique that has been shown to require less re-intervention than standard endoscopic enteral stenting for gastric outlet obstruction and is less invasive, quicker, and more cost-effective than surgery. This study evaluated the outcomes and safety of EUS-GE in patients treated for gastric outlet obstruction across two Australian centers.

METHODS

Retrospective data on demographics, presenting symptoms, disease, endoscopic and clinical outcomes, and safety were collected on all patients who underwent EUS-GE from 2021 to 2022. Descriptive statistics were used to evaluate outcomes and safety and survival were calculated using Kaplan-Meier analysis.

RESULTS

Eleven patients underwent EUS-GE during the defined period, 10 of whom had a malignant etiology (median age 73 years, interquartile range [IQR] 13; 63.6% male). Technical success was 90.9%. Of those patients, clinical success (the ability to tolerate at least a full liquid diet during follow-up) was 100%. The median length of hospital stay post-procedure was 6 days (IQR 14 days). No severe adverse events occurred, and one patient (10%) required a repeat endoscopy. Median survival post-EUS-GE was 298 days (95% confidence interval 0-730.1 days) CONCLUSION: EUS-GE is an effective, safe, and durable therapy for patients with gastric outlet obstruction. This study presents Australian data on outcomes and safety that is comparable to international literature. EUS-GE should be considered for patients where local expertise allows.

Gastrojejunocolic fistula after gastrojejunostomy in eastern Ethiopia: a case report

Gastrojejunocolic fistula (GJF) is an infrequent condition that presents late as a complication of gastroenterostomy conducted for complications of peptic ulcer disease and is believed to be a result of continuous acid secretion due to insufficient stomach resection and incomplete vagotomy. Symptoms of the fistula present late, usually 20 years or more after gastroenterostomy. Patients with GJF usually present with chronic on-and-off diarrhea, weight loss, fecal-smelling belching or vomiting, and malnutrition.

Case Presentation

The case is of a 45-year-old man with GJF who presented with diarrhea, weight loss, and foul-smelling vomiting. The diagnosis was made intraoperatively despite preoperative investigations with computerized tomography scan and endoscopy. The patient underwent a single-stage operation, and the postoperative course was uneventful.

Conclusion

Knowledge of this uncommon illness can aid in prevention through improved operative strategy and medical treatment during the stomal ulcer phase with proton pump inhibitor and Helicobacter pylori eradication.

Nasojejunal tube-assisted endoscopic ultrasound-guided gastrojejunostomy for the management of gastric outlet obstruction is safe and effective

Background and aims

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a therapeutic option for patients with gastric outlet obstruction (GOO), which provides long-term luminal patency without the risk of tumor ingrowth and/or overgrowth and avoids surgical morbidity. The goal of this study was to assess technical success, clinical success, and adverse events associated with a nasojejunal tube-assisted EUS- GJ technique.

Methods

This was a retrospective study conducted at a single tertiary care center. The nasojejunal tube (14F) was used to perform the EUS-GJ (device-assisted method). During the study period, consecutive GOO patients who underwent EUS-GJ between August 2018 and December 2021 were included. Technical success was defined as adequate positioning and deployment of the stent. The patient's ability to tolerate a normal oral diet without vomiting was defined as clinical success.

Results

Thirty patients underwent EUS-GJ during this study period. Twenty-six patients had malignant GOO, while four had a benign obstruction. EUS-GJ was successfully performed in 29 patients, and technical success was 96.67% (29/30). Nasojejunal tube-assisted EUS-GJ technique was used in all patients. Clinical success was achieved in all patients who had technical success (29/29, 100%). The adverse events rate was 6.6%. During the procedure, the median procedure time was 25 min (interquartile range 15-42.5), and the average hospitalization was 4.4 days. Normal meals were tolerated by all patients. After 210 days of median follow-up (range 5-880 days), no recurrence of symptoms was observed.

Conclusion

The nasojejunal tube-assisted EUS-GJ is a safe and effective technique to treat GOO symptoms.

Effects of Preoperative Oral Nutritional Supplements on Improving Postoperative Early Enteral Feeding Intolerance and Short-Term Prognosis for Gastric Cancer: A Prospective, Single-Center, Single-Blind, Randomized Controlled Trial

BACKGROUND

Early enteral nutrition (EN) after abdominal surgery can improve the prognosis of patients. However, the high feeding intolerance (FI) rate is the primary factor impeding postoperative EN.

METHODS

Sixty-seven patients who underwent radical subtotal or total gastrectomy for gastric cancer (GC) were randomly allocated to the preoperative oral nutritional supplement group (ONS group) or dietary advice alone (DA group). Both groups were fed via nasojejunal tubes (NJs) from the first day after surgery to the fifth day. The primary endpoint is the FI rate.

RESULTS

Of the patients, 66 completed the trial (31 in the ONS group, 35 in the DA group). The FI rate in the ONS group was lower than that in the DA group (25.8% vs. 31.4%, p = 0.249). The postoperative five-day 50% energy compliance rate in the ONS group was higher than that in the DA group (54.8% vs. 48.6%, p = 0.465). The main gastrointestinal intolerance symptoms were distension (ONS vs. DA: 45.2% vs. 62.9, p = 0.150) and abdominal pain (ONS vs. DA: 29.0% vs. 45.7%, p = 0.226). Postoperative nausea/vomiting rate and heartburn/reflux rate were similar between the two groups. We noted no difference in perioperative serum indices, short-term prognosis or postoperative complication rates between the two groups.

CONCLUSIONS

The study shows that short-term preoperative ONS cannot significantly improve FI and the energy compliance rate in the early stage after radical gastrectomy.

Retrieval anchor-assisted endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction

OBJECTIVES

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging procedure for gastric outlet obstruction (GOO) as an alternative to endoscopic stent placement in the duodenum or surgery; however, it is technically challenging. This study aimed to evaluate the safety, success rate, and adverse events rate associated with retrieval anchor-assisted EUS-GE.

METHODS

Data from patients who underwent retrieval anchor-assisted EUS-GE for malignant and benign GOO were retrospectively analyzed. Patients' clinical and demographic characteristics, procedure time, and success and adverse event rates were recorded.

RESULTS

A total of 10 patients (6 females; mean age 63.2 ± 5.8 years) were included in our study. Nine cases were malignant and one case was benign GOO. Nine patients received retrievable anchor-assisted EUS-GE for GOO. One patient received retrievable anchor-assisted EUS-GE and concurrent EUS-guided hepatogastrostomy due to the biliary obstruction. There were no complications during any of the procedures. The rate of technical and clinical success was 100%.

CONCLUSIONS

EUS-GE is a safe and effective procedure for GOO. The retrieval anchor can make EUS-GE easier to perform successfully.

EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction

BACKGROUND AND AIMS

Benign gastric outlet obstruction (GOO) has typically been managed surgically. However, many patients are poor operative candidates because of comorbidities. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has previously demonstrated efficacy as a definitive treatment for benign and malignant GOO; however, limited data exist on use as a bridge to resolution of the obstruction in an attempt to avoid or delay definitive surgery.

METHODS

A retrospective series of consecutive patients who underwent EUS-GE between January 2013 and July 2019 for benign GOO at a tertiary referral center were included in the study. The primary outcome was the rate of definitive surgery; secondary outcomes included technical success and rate of adverse events.

RESULTS

During the study period, 22 patients with benign GOO underwent EUS-GE (40% female; mean age, 54.2 years). The mean procedure time was 66 minutes, and technical success was achieved in 21. Five patients developed recurrent GOO while the LAMS was in place after a mean dwell time of 228 days; 1 patient was converted to surgical GE. LAMSs were removed electively in 18 patients after GOO resolution and a mean dwell time of 270 days; 1 patient developed a recurrent GOO after LAMS removal and was converted to surgical GE. The rate of recurrent GOO after LAMS removal was 5.6%. Three severe adverse events occurred in the cohort.

CONCLUSIONS

EUS-GE was able to prevent surgery for GOO in 83.3% of cases. LAMSs needed to stay in place for a mean of 8.5 months to allow resolution of GOO, and there was a low rate of recurrent GOO (5.6%) after LAMS removal. Prospective, randomized trials comparing surgical and endoscopic anastomoses are needed in patients with benign causes of GOO.

EUS-guided gastroenterostomy for the management of gastric outlet obstruction: A systematic review and meta-analysis

Gastric outlet obstruction (GOO) is characterized by epigastric pain and postprandial vomiting secondary to mechanical obstruction. Management of GOO is usually focused on alleviating the symptoms of obstruction and can be achieved by surgical gastrojejunostomy or enteral stenting. Recent studies have shown success with EUS-guided gastroenterostomy (EUS-GE) in the management of GOO but data is limited. We, therefore, conducted a meta-analysis to evaluate the safety and efficacy of EUS-GE in the management of GOO. A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to January 2019 to identify all studies that evaluate the efficacy and safety of EUS-GE in GOO. Our primary outcome was to evaluate technical success and clinical success. Secondary outcomes were to evaluate the need for reintervention and adverse events of the procedure. Twelve studies including 285 patients were included in the meta-analysis. Technical success was achieved in 266 patients with a pooled technical success of 92% (95% confidence interval [CI]: 88%-95%). Clinical success was achieved in 90% of the patients (95% CI: 85%-94%). Recurrence of symptoms or unplanned reintervention was needed in 9% of the patients (95% CI: 6%-13%) and adverse events were reported in 12% of the patients (95% CI: 8%-16%). The heterogeneity tests among studies were nonsignificant with I² = 0. EUS-GE is a safe and efficacious treatment modality for the management of benign and malignant GOO. Larger prospective studies are needed to further evaluate its utility in GOO.

Challenges of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrointestinal anatomy: A review article

Endoscopic retrograde cholangiopancreatography (ERCP) is a combination of endoscopy and fluoroscopy that is commonly used in the management of pancreatobiliary diseases. ERCP can be challenging if performed in surgically altered anatomy, such as a Billroth II reconstruction, compared with native anatomy and usually has a lower success rate. We identified five emerging challenges in such patients. These are the choice of endoscope, the identification of afferent loop, reaching the duodenal stump, cannulation in the reverse position, and endoscopic sphincterotomy. Performing ERCP in patients with a Billroth II reconstruction needs adequate knowledge, proper skill, and experience to achieve a good clinical outcome.

Thiamin, Pyridoxine, Vitamin D, and Carotene Deficiency in a Malnourished Patient Following Billroth II Gastrectomy

We describe the case of a malnourished 48-year-old man who had previously undergone a Billroth II procedure for severe peptic ulcer disease. He was found to have a severely stenotic gastrojejunal anastomosis with inflamed mucosa that prevented him from tolerating solid food. Laboratory assessment revealed deficiencies in thiamin, pyridoxine, vitamin D, and carotene. This case demonstrates potential vital micronutrient complications following a partial gastrectomy.

Gastric emptying scan after distal subtotal gastrectomy: Differences between Billroth I and II and predicting the presence of food residue at endoscopy

PURPOSE

We investigated whether gastric emptying scans (GESs) showed different emptying patterns between patients after different types of laparoscopic distal subtotal gastrectomies. We also investigated whether the presence of food residue via endoscopy can be predicted by GESs.

MATERIALS AND METHODS

We retrospectively enrolled patients who had GESs within postoperative week 1 after a Billroth I or Billroth II operation. Diabetic patients were excluded. GESs were done with a solid test meal. Percent emptying at each scan time was analyzed. The presence of food residue in the stomach and gastrointestinal symptoms at the outpatient clinic were also analyzed.

RESULTS

In total, 46 patients were enrolled (Billroth I: Billroth II = 21:25). Sixteen patients underwent a second GES (postoperative 3-6 months). Both groups showed delayed gastric emptying at the postoperative 1 week scan, but group I showed much slower emptying. However, this difference disappeared by the second scan. Based on endoscopies conducted 6 months after the operation, 73.2% of patients had significant amounts of food residue, which hindered an accurate evaluation. The proportion of patients with food residues did not differ between the groups. Receiver Operating Characteristic (ROC) curve analysis revealed that a cut-off value of ≤ 30% emptying at 100 min and 120 min in postoperative 3-6 month scans was both highly sensitive and specific for predicting the presence of food residue (90.91% and 75% for 100 min and 91.67% and 75% for 120 min, respectively).

CONCLUSIONS

GESs within a week after distal subtotal gastrectomy show slower emptying of Billroth I than II. At a ≤ 30% emptying threshold, a GES can predict subtotal gastrectomy patients who might have a significant amount of food residue in their stomach even after following typical fasting instructions to prepare endoscopy.

Palliative laparoscopic hepatico- and gastrojejunostomy for advanced pancreatic cancer

Only 10% to 20% of pancreatic tumors are resectable at the time of diagnosis. Patients with advanced disease have a median survival of 4.9 months. Palliation is often required for biliary or duodenal obstruction, or both, and for pain. Optimal palliation should guarantee the shortest possible hospital stay and as long a survival as possible with a good quality of life. In recent years, treatment options for palliation of biliary and duodenal obstruction due to pancreatic cancer have broadened. Endoscopic and percutaneous biliary stenting have been shown to be successful tools for safe palliation of high-risk patients. Nevertheless, fit patients with unresectable pancreatic cancer benefit from surgery, which allows long-lasting biliary and gastric drainage. While laparoscopic cholecystojejunostomy and gastroenterostomy in patients with advanced pancreatic cancer have been widely reported, laparoscopic hepatico-jejunostomy has been rarely described. In this article, we describe our technique of laparoscopic hepatico-jejunostomy and gastrojejunostomy. We also discuss current evidence on the indications for these procedures in patients with unresectable pancreatic cancer.

'Cross-section gastroenterostomy' in patients with irresectable periampullary carcinoma

BACKGROUND

The most frequent complication following gastroenterostomy (GE) for gastric outlet obstruction is delayed gastric emptying (DGE), which occurs in roughly 20% of patients. There is evidence that DGE may be linked to the longitudinal incision of the jejunum and that a transverse incision (cross-section GE) may decrease the incidence of DGE following GE.

PATIENTS AND METHODS

In contrast to the orthodox GE, the jejunum is severed transversely up to a margin of 1.5 cm at the mesenteric border and the anastomosis is created with a single running suture. A Braun anastomosis is added 20-30 cm distally to the GE. Patients were followed prospectively with special regard to the occurrence of DGE.

RESULTS

Between 1 August 1994 and 1 August 1998, 25 patients underwent cross-section GE, mostly because of an irresectable periampullary carcinoma. Eight patients exhibited clinical signs of gastric outlet obstruction preoperatively, while in 17 the GE was performed on a prophylactic basis. A biliary bypass was added in 15 patients. There was no disruption of the GE, but one patient died in hospital (4%). The nasogastric tube was withdrawn on the first postoperative day (range 0-6 days), a liquid diet was started on the fifth day (range 2-7 days) and a full regular diet was tolerated at a median of 9 days (6-14 days).The incidence of DGE was 4%: only the single patient who died fulfilled the formal criteria for DGE.

DISCUSSION

In contrast to orthodox GE, DGE seems to be of minor clinical importance following cross-section GE. As the technique is easy to perform, is free of specific complications and leads to a low incidence of DGE, it should be considered as an alternative to conventional GE.