Dynamics of perioperative pancreatic exocrine function in patients undergoing reconstruction after gastrectomy for gastric cancer

BACKGROUND

Each method of reconstruction after gastrectomy results in a change in the digestive and absorptive status. However, there are few reports on the changes in pancreatic exocrine function after gastrectomy. We conducted this study to investigate the dynamics of pancreatic exocrine function after gastrectomy according to the method of reconstruction performed.

METHODS

The subjects of this study were 45 patients who underwent pancreatic exocrine function tests preoperatively and postoperatively, from among all patients who underwent gastrectomy for gastric cancer at our hospital between September, 2020 and March, 2022. We assessed pancreatic exocrine function using the Pancreatic Function Diagnostant (PFD) test.

RESULT

The mean preoperative PFD test result values for the distal gastrectomy (DG) Billroth I reconstruction (B-I) group and the DG Roux-en-Y reconstruction (R-Y) group were 62.6 and 67.3 (p = 0.36), respectively, and the mean postoperative PFD test result values for each group were 65.8 and 46.9 (p = 0.0094), respectively. A significant decrease in postoperative pancreatic function was observed in the DG R-Y group but not in the DG B-I group. The logistic regression analysis identified that age and the R-Y group were significantly correlated with a 10% decrease in the PFD value after gastrectomy.

CONCLUSIONS

Our study suggests that R-Y reconstruction may result in more impaired pancreatic exocrine function than B-I reconstruction.

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.

Quality of Life Following the Surgical Management of Gastric Cancer Using Patient-Reported Outcomes: A Systematic Review

Introduction: Surgical management of gastric adenocarcinoma can have a drastic impact on a patient's quality of life (QoL). There is high variability among surgeons' preferences for the type of resection and reconstructive method. Peri-operative and cancer-specific outcomes remain equivalent between the different approaches. Therefore, postoperative quality of life can be viewed as a deciding factor for the surgical approach. The goal of this study was to interrogate patient QoL using patient-reported outcomes (PROs) following gastrectomy for gastric cancer. Methods: This systematic review was registered at Prospero and followed PRISMA guidelines. Medline, Embase, and Scopus were used to perform a literature search on 18 January 2020. A set of selection criteria and the data extraction sheet were predefined. Covidence (Melbourne, Australia) software was used; two reviewers (P.C.V. and E.J.) independently reviewed the articles, and a third resolved conflicts (A.B.F.). Results: The search yielded 1446 studies; 308 articles underwent full-text review. Ultimately, 28 studies were included for qualitative analysis, including 4630 patients. Significant heterogeneity existed between the studies. Geography was predominately East Asian (22/28 articles). While all aspects of quality of life were found to be affected by a gastrectomy, most functional or symptom-specific measures reached baseline by 6-12 months. The most significant ongoing symptoms were reflux, diarrhoea, and nausea/vomiting. Discussion: Generally, patients who undergo a gastrectomy return to baseline QoL by one year, regardless of the type of surgery or reconstruction. A subtotal distal gastrectomy is preferred when proper oncologic margins can be obtained. Additionally, no one form of reconstruction following gastrectomy is statistically preferred over another. However, for subtotal distal gastrectomy, there was a trend toward Roux-en-Y reconstruction as superior to abating reflux.

Comparative efficacy of uncut Roux-en-Y and Billroth II anastomosis in gastrointestinal reconstruction following laparoscopic radical gastrectomy for distal gastric cancer

This study retrospectively analyzed the clinical efficacy of Uncut Roux-en-Y and Billroth II anastomoses in gastrointestinal reconstruction following laparoscopic D2 radical gastrectomy for distal gastric cancer. The primary objective was to compare the postoperative outcomes, including quality of life and complication rates, between the 2 surgical techniques. One hundred patients diagnosed with distal gastric cancer were enrolled between June 2020 and May 2023. Patients underwent laparoscopic D2 gastrectomy and were categorized into either the Uncut Roux-en-Y or Billroth II anastomosis groups based on the technique used for gastrointestinal reconstruction. The inclusion and exclusion criteria were strictly followed. Surgical parameters, quality of life assessed using the Visick grading index, and postoperative complications were also evaluated. Statistical analyses were performed using SPSS version 27.0. The groups were comparable in terms of demographic and baseline clinical parameters. The Uncut Roux-en-Y group had a significantly longer duration of surgery (P < .001). However, there were no statistically significant differences in other surgical parameters. According to the Visick grading index, patients in the Uncut Roux-en-Y group reported a significantly better quality of life than those in the Billroth II group (P < .05). Additionally, Uncut Roux-en-Y was associated with a significantly lower incidence of dumping syndrome and bile reflux (P < .05). Although Uncut Roux-en-Y anastomosis requires longer surgical time, it offers significant advantages in terms of postoperative quality of life and reduced rates of dumping syndrome and bile reflux. Our findings suggest that Uncut Roux-en-Y may be a superior option for gastrointestinal reconstruction after laparoscopic D2 gastrectomy for distal gastric cancer.

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.

Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial

BACKGROUND

Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel endoscopic method to palliate malignant gastric outlet obstruction. We aimed to assess whether the use of EUS-GE with a double balloon occluder for malignant gastric outlet obstruction could reduce the need for reintervention within 6 months compared with conventional duodenal stenting.

METHODS

The was an international, multicentre, randomised, controlled trial conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy, and Spain. Consecutive patients (aged ≥18 years) with malignant gastric outlet obstruction due to unresectable primary gastroduodenal or pancreatobiliary malignancies, a gastric outlet obstruction score (GOOS) of 0 (indicating an inability in intake food or liquids orally), and an Eastern Cooperative Oncology Group performance status score of 3 or lower were included and randomly allocated (1:1) to receive either EUS-GE or duodenal stenting. The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of the stent due to tumour ingrowth, tumour overgrowth, or food residue; stent migration; or stent fracture) within 6 months, analysed in the intention-to-treat population. Prespecified secondary outcomes were technical success (successful placement of a stent), clinical success (1-point improvement in gastric outlet obstruction score [GOOS] within 3 days), adverse events within 30 days, death within 30 days, duration of stent patency, GOOS at 1 month, and quality-of-life scores. This study is registered with ClinicalTrials.gov (NCT03823690) and is completed.

FINDINGS

Between Dec 1, 2020, and Feb 28, 2022, 185 patients were screened and 97 (46 men and 51 women) were recruited and randomly allocated (48 to the EUS-GE group and 49 to the duodenal stent group). Mean age was 69·5 years (SD 12·6) in the EUS-GE group and 64·8 years (13·0) in the duodenal stent group. All randomly allocated patients completed follow-up and were analysed. Reintervention within 6 months was required in two (4%) patients in the EUS-GE group and 14 (29%) in the duodenal stent group [p=0·0020; risk ratio 0·15 [95% CI 0·04-0·61]). Stent patency was longer in the EUS-GE group (median not reached in either group; HR 0·13 [95% CI 0·08-0·22], log-rank p<0·0001). 1-month GOOS was significantly better in the EUS-GE group (mean 2·41 [SD 0·7]) than the duodenal stent group (1·91 [0·9], p=0·012). There were no statistically significant differences between the EUS-GE and duodenal stent groups in death within 30 days (ten [21%] vs six [12%] patients, respectively, p=0·286), technical success, clinical success, or quality-of-life scores at 1 month. Adverse events occurred 11 (23%) patients in the EUS-GE group and 12 (24%) in the duodenal stent group within 30 days (p=1·00); three cases of pneumonia (two in the EUS-GE group and one in the duodenal stent group) were considered to be procedure related.

INTERPRETATION

In patients with malignant gastric outlet obstruction, EUS-GE can reduce the frequency of reintervention, improve stent patency, and result in better patient-reported eating habits compared with duodenal stenting, and the procedure should be used preferentially over duodenal stenting when expertise and required devices are available.

FUNDING

Research Grants Council (Hong Kong Special Administrative Region, China) and Sociedad Española de Endoscopia Digestiva.

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis

BACKGROUND

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness.

METHODS

Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups.

RESULTS

During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively.

CONCLUSION

R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

EUS-guided gastroenterostomy for gastric outlet obstruction: a comprehensive meta-analysis

OBJECTIVE

A comprehensive meta-analysis was performed to evaluate the efficacy and safety of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for benign and malignant gastric outlet obstruction (GOO).

MATERIAL AND METHODS

PubMed, Embase, Web of Science and Cochrane Library were searched to identify relevant studies. The primary outcomes evaluated technical success, clinical success, and adverse events (AEs).

RESULTS

Twenty‑six studies with 1493 patients were included in this meta-analysis. The pooled rates of technical success, clinical success, and overall AEs of EUS-GE were 94.0%, 89.9%, and 13.1%, respectively. Eight studies were included in the subgroup meta-analysis for comparative evaluation of EUS-GE and surgical gastroenterostomy (SGE), while seven studies were for EUS-GE and enteral stenting (ES). Compared with SGE, the pooled odds ratios (ORs) of technical success, clinical success, and overall AEs of EUS-GE were 0.17 (p = .003), 1.42 (p = .40), and 0.15 (p < .00001), respectively. When compared with ES, the above corresponding pooled ORs were 0.55 (p = .11), 2.64 (p < .0001), and 0.41 (p = .01), respectively.

CONCLUSION

Although it is technically challenging, this largest meta-analysis indicates that EUS‑GE has comparable and high technical and clinical success rates and hence a very effective minimally invasive procedure for GOO.

Short- and long-term outcomes of Roux-en-Y and Billroth II with Braun reconstruction in total laparoscopic distal gastrectomy: a retrospective analysis

BACKGROUND

The controversy surrounding Roux-en-Y (R-Y) and Billroth II with Braun (BII + B) reconstruction as an anti-bile reflux procedure after distal gastrectomy has persisted. Recent studies have demonstrated their efficacy, but the long-term outcomes and postoperative quality of life (QoL) among patients have yet to be evaluated. Therefore, we compared the short-term and long-term outcomes of the two procedures as well as QoL.

METHODS

The clinical data of 151 patients who underwent total laparoscopic distal gastrectomy (TLDG) at the Gastrointestinal Surgery Department of the Second Hospital of Fujian Medical University from January 2016 to December 2019 were retrospectively analyzed. Of these, 57 cases with Roux-en-Y procedure (R-Y group) and 94 cases with Billroth II with Braun procedure were included (BII + B group). Operative and postoperative conditions, early and late complications, endoscopic outcomes at year 1 and year 3 after surgery, nutritional indicators, and quality of life scores at year 3 postoperatively were compared between the two groups.

RESULTS

The R-Y group recorded a significantly longer operative time (194.65 ± 21.52 vs. 183.88 ± 18.02 min) and anastomotic time (36.96 ± 2.43 vs. 27.97 ± 3.74 min) compared to the BII + B group (p < 0.05). However, no other significant differences were observed in terms of perioperative variables, including blood loss (p > 0.05). Both groups showed comparable rates of early and late complications. Endoscopic findings indicated similar food residuals at years 1 and 3 post-surgery for both groups. The R-Y group had a lower occurrence of residual gastritis and bile reflux at year 1 and year 3 after surgery, with a statistically significant difference (p < 0.001). Reflux esophagitis was not significantly different between the R-Y and BII + B groups in year 1 after surgery (p = 0.820), but the R-Y group had a lower incidence than the BII + B group in year 3 after surgery (p = 0.023). Nutritional outcomes at 3 years after surgery did not differ significantly between the two groups (p > 0.05). Quality of life scores measured by the QLQ-C30 scale were not significantly different between the two groups. However, on the QLQ-STO22 scale, the reflux score was significantly lower in the R-Y group than in the BII + B group (0 [0, 0] vs. 5.56 [0, 11.11]) (p = 0.003). The rest of the scores were not significantly different (p > 0.05).

CONCLUSION

Both R-Y and B II + B reconstructions are equally safe and efficient for TLDG. Nevertheless, the R-Y reconstruction reduces the incidence of residual gastritis, bile reflux, and reflux esophagitis, as well as postoperative reflux symptoms, and provides a better quality of life for patients. R-Y reconstruction is superior to BII + B reconstruction for TLDG.

Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stents: a retrospective multicentric comparison of wireless and over-the-wire techniques

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) appears to be effective and safe in gastric outlet obstruction (GOO); however, the EUS-GE procedure is not standardized, with the use of assisted or direct methods still debated. The aim of this study was to compare the outcomes of EUS-GE techniques focusing on an assisted with orointestinal drain wireless endoscopic simplified technique (WEST) and the nonassisted direct technique over a guidewire (DTOG).

METHOD

This was a multicenter European retrospective study involving four tertiary centers. Consecutive patients who underwent EUS-GE for GOO between August 2017 and May 2022 were included. The primary aim was to compare the technical success and adverse event (AE) rates of the different EUS-GE techniques. Clinical success was also analyzed.

RESULTS

71 patients (mean [SD] age 66.2 10 years; 42.3 % men; 80.3 % malignant etiology) were included. Technical success was higher in the WEST group (95.1 % vs. 73.3 %; estimate of relative risk from odds ratio (eRR) 3.2, 95 %CI 0.94-10.9; P = 0.01). The rate of AEs was lower in the WEST group (14.6 % vs. 46.7 %; eRR 2.3, 95 %CI 1.2-4.5; P = 0.007). Clinical success was comparable between the two groups at 1 month (97.5 % vs. 89.3 %). The median follow-up was 5 months (range 1-57).

CONCLUSION

The WEST resulted in a higher technical success rate with fewer AEs, with clinical success comparable with the DTOG. Therefore, the WEST (with an orointestinal drain) should be preferred when performing EUS-GE.

Can prospective monitoring improve complication rates after gastrectomy? Experience of Billroth I reconstruction at a high-volume tertiary center

INTRODUCTION

Prospective database is imperative in surgical outcome monitoring and has shown success in providing a comprehensive complication index to monitor surgical quality. This study aims to review whether prospective monitoring has an effect on postoperative complication rates, especially leakage after Billroth I (BI) anastomosis and to identify risk factors of anastomosis leakage after BI anastomosis.

MATERIALS AND METHODS

Patients who underwent distal gastrectomy with BI reconstruction at Seoul National University Hospital between January 2018 and April 2021 were enrolled. Clinicopathological characteristics and perioperative variables were retrieved. The risk factor that was statistically significant in univariate analysis was further analyzed by binomial logistic regression analysis.

RESULTS

BI leakage rate in three years has declined by half on a yearly basis from 5.7% to 1.8%. The leakage group patients were predominantly male (100%) when compared to the non-leakage group (67.6%) (p = 0.04). The BMI (25.00 ± 1.42 vs. 24.16 ± 3.15, p = 0.048) and CRP measured on POD#2 (16.47 ± 5.64 vs. 9.99 ± 5.42, p < 0.001) showed significant differences between the two groups. POD#2 CRP greater than 12.7 mg/dL was able to predict risk of anastomosis leak with sensitivity 73.3% and specificity 73.1%.

CONCLUSION

Understanding variations in outcomes is important for improvements in surgical care, and through prospective monitoring and intra-departmental feedback, it is possible to reduce complication rates after gastrectomy. This study shows that age, gender and BMI are risk factors to BI leakage and POD#2 CRP greater than 12.7 mg/dL can be used to suspect leakage after BI anastomosis.

Successful treatment of gastric cancer with gastroduodenal intussusception by laparoscopic distal gastrectomy

We report a case of a 93-year-old woman with gastric cancer who presented with gastroduodenal intussusception and was treated with laparoscopic distal gastrectomy. Esophagogastroduodenoscopy showed a giant protruding lesion in the gastric antrum extending into the duodenal bulb, and biopsy confirmed a well-differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement and a stalk arising from the distal stomach extending into the duodenal bulb. With a clinical diagnosis of gastric cancer with gastroduodenal intussusception, the patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and reconstruction using the Billroth I method. Reduction of the intussusception was performed through a 4 cm incision under the xiphoid process in the epigastric region because it could not be laparoscopically reduced. Gross examination of the resected specimen showed a well-circumscribed, elevated lesion measuring 11.2 × 4.7 × 3.6 cm in the antrum. Microscopic examination of the elevated tumor confirmed the diagnosis of well-differentiated adenocarcinoma invading the gastric submucosal layer without lymph node metastasis. There was no lymphatic or venous invasion or lymph node metastasis. The postoperative course was uneventful, and her hemoglobin level improved to 11.9 g/dL. The patient has been postoperatively well without evidence of recurrence for 3 months. Part of the superficial spreading-type tumor may be drawn into the duodenum under strong peristaltic movement because it does not infiltrate the muscle layer.

EUS-guided gastroenterostomy for management of malignant gastric outlet obstruction: a prospective cohort study with matched comparison with enteral stenting

BACKGROUND AND AIMS

Retrospective studies on malignant gastric outlet obstruction (mGOO) highlighted several advantages of EUS-guided gastroenterostomy (EUS-GE) over enteral stenting (ES). However, no prospective evidence is available. The aim of this study was to report on clinical outcomes of EUS-GE in a prospective cohort study, with a subgroup comparison versus ES.

METHODS

All consecutive patients endoscopically treated for mGOO between December 2020 and December 2022 in a tertiary, academic center were enrolled in a prospective registry (Prospective Registry of Therapeutic Endoscopic Ultrasound [PROTECT]; NCT04813055) and followed up every 30 days to register efficacy/safety outcomes. EUS-GE and ES cohorts were matched according to baseline frailty and oncologic disease.

RESULTS

A total of 104 patients were treated for mGOO during the study; 70 (58.6% male subjects; median age, 64 [interquartile range, 58-73] years; 75.7% pancreatic cancer, 60.0% metastatic cancer) underwent EUS-GE via the wireless simplified technique. Technical success was 97.1% and clinical success was 97.1% after a median of 1.5 (interquartile range, 1-2) days. Adverse events occurred in 9 (12.9%) patients. After a median follow-up of 105 (49-187) days, symptom recurrence was 7.6%. In the matched comparison versus ES (28 patients per arm), EUS-GE-treated patients experienced higher and faster clinical success (100% vs 75.0%, P = .006), reduced recurrences (3.7% vs 33.3%, P = .02), and a trend toward shorter time to chemotherapy.

CONCLUSIONS

In this first, prospective, single-center comparison, EUS-GE showed excellent efficacy in treating mGOO, with an acceptable safety profile and long-term patency, and several clinically significant advantages over ES. While awaiting randomized trials, these results might endorse EUS-GE as first-line strategy for mGOO, where adequate expertise is available.

Same-session double EUS-guided bypass versus surgical gastroenterostomy and hepaticojejunostomy: an international multicenter comparison

BACKGROUND AND AIMS

Gastric outlet and biliary obstruction are common manifestations of GI malignancies and some benign diseases for which standard treatment would be surgical gastroenterostomy and hepaticojejunostomy (ie, "double bypass"). Therapeutic EUS has allowed for the creation of an EUS-guided double bypass. However, same-session double EUS-guided bypass has only been described in small proof-of-concept series and lacks a comparison with surgical double bypass.

METHODS

A retrospective multicenter analysis was performed of all consecutive same-session double EUS-guided bypass procedures performed in 5 academic centers. Surgical comparators were extracted from these centers' databases from the same time interval. Efficacy, safety, hospital stay, nutrition and chemotherapy resumption, long-term patency, and survival were compared.

RESULTS

Of 154 identified patients, 53 (34.4%) received treatment with EUS and 101 (65.6%) with surgery. At baseline, patients undergoing EUS exhibited higher American Society of Anesthesiologists scores and a higher median Charlson Comorbidity Index (9.0 [interquartile range {IQR}, 7.0-10.0] vs 7.0 [IQR, 5.0-9.0], P < .001). Technical success (96.2% vs 100%, P = .117) and clinical success rates (90.6% vs 82.2%, P = .234) were similar when comparing EUS and surgery. Overall (11.3% vs 34.7%, P = .002) and severe adverse events (3.8% vs 19.8%, P = .007) occurred more frequently in the surgical group. In the EUS group, median time to oral intake (0 days [IQR, 0-1] vs 6 days [IQR, 3-7], P < .001) and hospital stay (4.0 days [IQR, 3-9] vs 13 days [IQR, 9-22], P < .001) were significantly shorter.

CONCLUSIONS

Despite being used in a patient population with more comorbidities, same-session double EUS-guided bypass achieved similar technical and clinical success and was associated with fewer overall and severe adverse events when compared with surgical gastroenterostomy and hepaticojejunostomy.

Prospective multicenter assessment of the impact of EUS-guided gastroenterostomy on patient quality of life in unresectable malignant gastric outlet obstruction

BACKGROUND AND AIMS

EUS-guided gastroenterostomy (EUS-GE) is increasingly used for malignant gastric outlet obstruction (GOO) in inoperable patients. However, the impact of EUS-GE on patient quality of life (QoL) has not been evaluated prospectively.

METHODS

Consecutive patients with unresectable malignant GOO who underwent EUS-GE between August 2019 and May 2021 at 4 Spanish centers were prospectively assessed using the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 at baseline and 1 month after the procedure. Centralized follow-up by telephone calls was undertaken. The Gastric Outlet Obstruction Scoring System (GOOSS) was used to assess oral intake, defining clinical success as a GOOSS ≥2. Differences between baseline and 30-day QoL scores were assessed using a linear mixed model.

RESULTS

Sixty-four patients were enrolled, 33 (51.6%) men, with a median age of 77.3 years (interquartile range, 65.5-86.5). The most common diagnoses were pancreatic (35.9%) and gastric (31.3%) adenocarcinoma. Thirty-seven patients (57.9%) presented a 2/3 baseline Eastern Cooperative Oncology Group performance status score. Oral intake was restarted within 48 hours in 61 patients (95.3%), and the median postprocedure hospital stay was 3.5 days (interquartile range, 2-5). The 30-day clinical success rate was 83.3%. A clinically significant increase of 21.6 points (95% confidence interval, 11.5-31.7) in the global health status scale was documented, with significant improvements in nausea and vomiting, pain, constipation, and appetite loss.

CONCLUSIONS

EUS-GE relieves GOO symptoms in patients with unresectable malignancy, allowing rapid oral intake and hospital discharge. It also provides a clinically relevant increase in QoL scores at 30 days from baseline. (Clinical trial registration number: NCT04660695.).

Comparison of long-term quality of life between Billroth-I and Roux-en-Y anastomosis after distal gastrectomy for gastric cancer: a randomized controlled trial

BACKGROUND

The results of studies comparing Billroth-I (B-I) with Roux-en-Y (R-Y) reconstruction on the quality of life (QoL) are still inconsistent. The aim of this trial was to compare the long-term QoL of B-I with R-Y anastomosis after curative distal gastrectomy for gastric cancer.

METHODS

A total of 140 patients undergoing curative distal gastrectomy with D2 lymphadenectomy in West China Hospital, Sichuan University from May 2011 to May 2014 were randomly assigned to the B-I group ( N  = 70) and R-Y group ( N  = 70). The follow-up time points were 1, 3, 6, 9, 12, 24, 36, 48, and 60 months after the operation. The final follow-up time was May 2019. The clinicopathological features, operative safety, postoperative recovery, long-term survival as well as QoL were compared, among which QoL score was the primary outcome. An intention-to-treat analysis was applied.

RESULTS

The baseline characteristics were comparable between the two groups. There were no statistically significant differences in terms of postoperative morbidity and mortality rates, and postoperative recovery between the two groups. Less estimated blood loss and shorter surgical duration were found in the B-I group. There were no statistically significant differences in 5-year overall survival (79% [55/70] of the B-I group vs. 80% [56/70] of the R-Y group, P  = 0.966) and recurrence-free survival rates (79% [55/70] of the B-I group vs. 78% [55/70] of the R-Y group, P  = 0.979) between the two groups. The scores of the global health status of the R-Y group were higher than those of the B-I group with statistically significant differences (postoperative 1 year: 85.4 ± 13.1 vs . 88.8 ± 16.1, P  = 0.033; postoperative 3 year: 87.3 ± 15.2 vs . 92.8 ± 11.3, P  = 0.028; postoperative 5 year: 90.9 ± 13.7 vs . 96.4 ± 5.6, P  = 0.010), and the reflux (postoperative 3 year: 8.8 ± 12.9 vs . 2.8 ± 5.3, P  = 0.001; postoperative 5 year: 5.1 ± 9.8 vs . 1.8 ± 4.7, P  = 0.033) and epigastric pain (postoperative 1 year: 11.8 ± 12.7 vs. 6.1 ± 8.8, P  = 0.008; postoperative 3 year: 9.4 ± 10.6 vs. 4.6 ± 7.9, P  = 0.006; postoperative 5 year: 6.0 ± 8.9 vs . 2.7 ± 4.6, P  = 0.022) were milder in the R-Y group than those of the B-I group at the postoperative 1, 3, and 5-year time points.

CONCLUSIONS

Compared with B-I group, R-Y reconstruction was associated with better long-term QoL by reducing reflux and epigastric pain, without changing survival outcomes.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR-TRC-10001434.

The formation process and mechanism of gastrointestinal anastomosis after retrieval anchor-assisted endoscopic ultrasound-guided gastroenterostomy: a preclinical study

BACKGROUND AND AIMS

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a promising method of treating gastric outlet obstruction. However, no study has investigated gastrointestinal anastomosis formation after EUS-GE. We aimed to evaluate the formation of gastrointestinal anastomosis after EUS-GE in a porcine model.

METHODS

Retrieval anchor-assisted EUS-GE was performed on 15 Bama mini pigs. Five pigs each were randomly euthanized 3, 7, and 14 days postoperatively to evaluate the formation of gastrointestinal anastomosis and measure the anastomotic distance. The expression of transforming growth factor-β1(TGF-β1) and Smad3 in the anastomosis site were examined by immunohistochemistry.

RESULTS

EUS-GE was successfully performed in all 15 pigs. The mean procedure time was 29.2 ± 6.0 (range 18-40) minutes. The anastomotic distance was 34.0 ± 3.6 cm in 14 pigs. The site of gastroenterostomy of one pig was at the ileum. For pigs euthanized 3 days postoperatively, the structure was mechanically maintained by a stent. For pigs euthanized 7 or 14 days postoperatively, the stomach and small intestine were anastomosed to form a stable structure. The level of TGF-β1 and Smad3 in the anastomosis site gradually increased from 3 to 14 days after EUS-GE. TGF-β1 and Smad3 expression had a significant difference between 3 days, 7 days, and 14 days after EUS-GE (P < 0.05).

CONCLUSIONS

For EUS-GE, the stomach and small intestine were initially linked together mechanically and spontaneously anastomosed to form a stable structure 7 days postoperatively. TGF-β1 and Smad3 play an important role in the formation of a stable structure of gastrointestinal anastomosis.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy

PURPOSE

This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively.

METHODS

We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5).

RESULTS

Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups.

CONCLUSIONS

L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

Optimizing outcomes for EUS-guided gastroenterostomy: results of a Standardized Clinical Assessment and Management Plan (with video)

BACKGROUND AND AIMS

EUS-guided gastroenterostomy (EUS-GE) has emerged as an option for managing malignant gastric outlet obstruction (GOO). However, there is currently no standardized technique, and outcomes are variable with inconsistencies both within and across centers. The present study aims to develop and assess outcomes of a Standardized Clinical and Assessment Management Plan (SCAMP) for EUS-GE.

METHODS

A SCAMP was created by a multidisciplinary team to develop and optimize a systematic approach for EUS-GE. This is a single-center, prospective cohort study on patients undergoing EUS-GE for GOO, using the developed SCAMP. Baseline demographics, cancer diagnosis and stage, Eastern Cooperative Oncology Group (ECOG) performance score, clinical and technical success, adverse events (AEs), and obstruction recurrence were collected. Primary outcomes included technical and clinical success. Obstruction-free and overall survival were calculated and compared with Kaplan-Meier analysis.

RESULTS

Fifty patients underwent EUS-GE in accordance with the SCAMP. Mean age was 67 years, 54% were women, and pancreatic cancer represented the largest cancer type (51%). Technical success was 100% and clinical success 92%. AEs occurred in 2 patients (4%). Recurrent obstruction occurred in 16%, related to distal small-bowel obstruction from carcinomatosis. Estimated mean obstruction-free survival was 217 days. Median overall survival was 230 days among patients with ECOG scores 0 to 2 and 82 days for ECOG scores ≥3 (P = .008).

CONCLUSIONS

The standardized technique used was associated with high technical and clinical success and low rates of AEs, morbidity and procedure-related mortality. Adopting a similar uniform systematic approach may improve procedural outcomes and dissemination.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Effectiveness and safety of a laparoscopic training system combined with modified reconstruction techniques for total laparoscopic distal gastrectomy

BACKGROUND

Total laparoscopic distal gastrectomy (TLDG) is increasing due to some advantages over open surgery, which has generated interest in gastrointestinal surgeons. However, TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction. During the course of training, trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons.

AIM

To evaluate an appropriate, efficient and safe laparoscopic training procedures suitable for trainee surgeons.

METHODS

Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed. The trainees were taught a laparoscopic view of surgical anatomy, standard operative procedures and practiced essential laparoscopic skills. The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills. Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees. Learning curves were used to assess the utility of our training system.

RESULTS

Five trainees performed a total of 52 TLDGs (56.5%), while 40 TLDGs were conducted by two trainers (43.5%). Except for depth of invasion and pathologic stage, there were no differences in clinicopathological characteristics. Trainers performed more D2 gastrectomies than trainees. The total operation time was significantly longer in the trainee group. The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups. No difference was found in postoperative complications between the two groups. The learning curve of the trainees plateaued after five TLDG cases.

CONCLUSION

Preparing trainees with a laparoscopic view of surgical anatomy, standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.

Modified delta-shaped gastroduodenostomy consisting of linear stapling and single-layer suturing with the operator positioned between the patient's legs: A technique preventing intraoperative duodenal injury and postoperative anastomotic stenosis

Background

The drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter.

Materials and methods

From June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient’s legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series.

Results

No intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30–45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis.

Conclusions

We suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient’s legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

The investigation of diet recovery after distal gastrectomy

This study aims to investigate the adaptation process of the alimentary tract after distal gastrectomy and understand the impact of remnant stomach volume (RSV) on diet recovery.One year after gastrectomy, although patients' oral intake had increased, the RSV was decreased and small bowel motility was enhanced. Patients with a larger RSV showed no additional benefits regarding nutritional outcomes.We prospectively enrolled patients who underwent distal gastrectomy with Billroth II reconstruction to treat gastric cancer at a tertiary hospital cancer center between September 2009 and February 2012. Demographic data, diet questionnaires, computed tomography (CT), and contrast fluoroscopy findings were collected. Patients were divided into 2 groups according to the RSV calculated using CT gastric volume measurements (large vs small). Dietary habits and nutritional status were compared between the groups.Seventy-eight patients were enrolled. Diet volume recovered to 90% of baseline by the 36 postoperative month, and RSV was 70% of baseline at 6 months after surgery and gradually decreased over time. One year after surgery, small bowel transit time was 75% compared to the 1st postoperative month (P < .05); however, transit time in the esophagus and remnant stomach showed no change in any studied interval. Compared to patients with a small RSV, those with a large RSV showed no differences in diet volume, habits, or other nutritional benefits (P > .05).Diet recovery for distal gastrectomy patients was achieved by increased small bowel motility. The size of the remnant stomach showed no positive impact on nutritional outcomes.

Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: A retrospective study of long-term functional outcomes and quality of life

BACKGROUND

Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was known to have benefits of function-preserving surgery compared to laparoscopy-assisted distal gastrectomy (LADG). However, in clinical settings, delayed gastric emptying and esophageal reflux following LAPPG can be serious issues, making surgeons reluctant to perform LAPPG. It is unclear that LAPPG had better long-term functional outcomes and quality of life compared to LADG.

AIM

To evaluate the long-term functional outcomes and patient-reported quality of life of LAPPG compared to those of LADG.

METHODS

We reviewed the clinicopathological data of 195 patients who underwent LADG with Billroth II anastomosis and 101 patients who underwent LAPPG for cT1N0 gastric cancer in the middle third of the stomach between 2012 and 2015. Postoperative complications, nutritional parameters, and survey results of the European Organization for Research and Treatment of Cancer Questionnaire C30 and STO22 questionnaire were compared between the two groups.

RESULTS

The serum hemoglobin level was significantly higher in the LAPPG group than in the LADG group (P < 0.001). In the endoscopic findings, incidence of bile reflux was lower (P < 0.001); however, the incidence of residual food was higher in the LAPPG group than in the LADG group (P < 0.001). Regarding the quality of life score, the LAPPG group had a better physical functioning score (86.7 vs 90.0, P = 0.032) but also greater pain and reflux when compared to the LADG group [8.3 vs 16.7 in pain, 11.1 (interquartile range, 0, 22.2) vs 11.1 (interquartile range, 11.1, 33.3) in reflux, P = 0.034 and 0.001, respectively].

CONCLUSION

LAPPG is beneficial to recovery of anemia and to bile reflux, however, it might be unfavorable in terms of pain and reflux symptoms compared to LADG with Billroth II anastomosis.

EUS-Guided Endoscopic Gastrointestinal Anastomosis with Lumen-Apposing Metal Stent: Feasibility, Safety, and Efficacy

Traditionally, restoration of normal bowel continuity after resection and bypass of a diseased or obstructed gastrointestinal tract can only be achieved through surgery, which can be technically challenging and comes with a risk of adverse events. Here, we describe our institutions' experience with endoscopic-guided gastroenterostomy or enteroenterostomy with lumen-apposing metal stent (LAMS) from March 2015 to August 2016. Ten patients had gastrogastrostomy (gastric pouch to gastric remnant) and three patients had jejunogastrostomy (Roux limb to gastric remnant) for the reversal of Roux-en-Y bariatric surgery. One patient had gastroduodenostomy (stomach to duodenal bulb) post antrectomy and one patient had jejunojejunostomy for distal obstruction following Roux-en-Y reconstruction. Technical and clinical success were achieved in all patients, save for delayed anastomotic stenosis following stent removal in one patient, with a mean follow-up of 126 days (3-318 days) with minimal complications in two patients. Endoscopic gastrointestinal anastomosis therefore may be a safe and feasible technique to re-establish continuity of the digestive system following bypass in the short-term.

Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.

AIM

To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.

METHODS

A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.

RESULTS

A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).

CONCLUSION

The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.

Self-expanding metal stent procedure for afferent loop syndrome with ascending cholangitis caused by remnant gastric cancer: A case report

RATIONALE

Self-expanding metal stent placement is a useful procedure for intestinal obstruction. Afferent loop syndrome after gastrectomy is an uncommon complication of gastroenterostomy reconstruction. Ascending cholangitis caused by afferent loop syndrome is a potential, but rare, complication.

PATIENT CONCERNS

A 73-year-old man with abdominal pain and vomiting was admitted to the emergency room. His medical history was significant for subtotal gastrectomy with Billroth II anastomosis for benign gastric ulcer perforation 40 years prior. He had notable tenderness to palpation, particularly on the epigastric area, and a temperature of 39.0°C.

DIAGNOSIS

Abdominal computed tomography revealed afferent loop syndrome with ascending cholangitis caused by remnant gastric cancer.

INTERVENTIONS

Percutaneous catheter drainage for management of ascending cholangitis was performed on the day of admission. He was subsequently treated with self-expandable metal stent insertion into the stenotic lesion.

OUTCOMES

After treatment with percutaneous transhepatic insertion of a self-expanding stent, the patient achieved complete resolution of symptoms. The patient died of disease progression 2 months later, without further recurrence of afferent loop syndrome.

LESSONS

Our case shows that insertion of a metal stent via percutaneous transhepatic biliary drainage (PTBD) can effectively treat ascending cholangitis and resolve afferent loop syndrome in inoperable patients.

[Research advance in Billroth II with Braun anastomosis after distal gastrectomy]

Methods of digestive tract reconstruction after distal gastrectomy include Billroth I, Billroth II and Roux-en-Y. Each of them has advantages and disadvantages respectively. Alkaline reflux gastritis (ARG) is one of the complications after distal gastrectomy, which is common after Billroth II. In the past 100 years, the ways of digestive tract reconstruction have been continuously improved and developed to prevent the occurrence of alkaline reflux gastritis, and Roux-en-Y is one of them. Still, there is a high incidence of Roux stasis syndrome resulting from Roux-en-Y, with impact on quality of life. Therefore, the appropriate reconstruction is needed urgently. Braun anastomosis was proposed in 1892 to lower the incidence of afferent syndrome. Because of its effect of diverting some alkaline digestive juice, it was applied to pancreaticoduodenectomy and distal gastrectomy. Some studies have proved its effect of diverting some alkaline digestive juice, but the diverted quantity was rarely shown. Besides, compared with Roux-en-Y, Billroth II with Braun anastomosis is safer and more convenient. Meantime it is likely to have benefits in aspect of preventing anemia and malnutrition. In order to provide evidence to clinical practice, this article summarizes the history and research advance of Billroth II with Braun anastomosis by reviewing previous reports.

Comparison between uncut Roux-en-Y and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: A meta-analysis

AIM

To compare uncut Roux-en-Y (U-RY) gastrojejunostomy with Roux-en-Y (RY) gastrojejunostomy after distal gastrectomy (DG) for gastric cancer.

METHODS

A literature search was conducted in Pubmed, Embase, Web of Science, Cochrane Library, Science Direct, Chinese National Knowledge Infrastructure, Wanfang, and China Science and Technology Journal Database to identify studies comparing U-RY with RY after DG for gastric cancer until the end of December 2017. Pooled odds ratio or weighted mean difference with 95% confidence interval was calculated using either fixed- or random-effects models. Perioperative outcomes such as operative time, intraoperative blood loss, and hospital stay; postoperative complications such as anastomotic bleeding, stricture and ulcer, reflux gastritis/esophagitis, delayed gastric emptying, and Roux stasis syndrome; and postoperative nutritional status (serum hemoglobin, total protein, and albumin levels) were the main outcomes assessed. Meta-analyses were performed using RevMan 5.3 software.

RESULTS

Two randomized controlled trials and four nonrandomized observational clinical studies involving 403 and 488 patients, respectively, were included. The results of the meta-analysis showed that operative time [weighted mean difference (WMD): -12.95; 95%CI: -22.29 to -3.61; P = 0.007] and incidence of reflux gastritis/esophagitis (OR: 0.40; 95%CI: 0.20-0.80; P = 0.009), delayed gastric emptying (OR: 0.29; 95%CI: 0.14-0.61; P = 0.001), and Roux stasis syndrome (OR: 0.14; 95%CI: 0.04-0.50; P = 0.002) were reduced; and the level of serum albumin (WMD: 0.71; 95%CI: 0.24-1.19; P = 0.003) was increased in patients undergoing U-RY reconstruction compared with those undergoing RY reconstruction. No differences were found with respect to intraoperative blood loss, hospital stay, anastomotic bleeding, anastomotic stricture, anastomotic ulcer, the levels of serum hemoglobin, and serum total protein.

CONCLUSION

U-RY reconstruction has some clinical advantages over RY reconstruction after DG.

Laparoscopic distal gastrectomy for clinical stage I gastric adenocarcinoma: Techniques evolution and oncological outcomes of the first 100 cases

BACKGROUND/PURPOSE

While gaining more acceptance, the use of laparoscopic distal gastrectomy (LDG) to treat gastric cancer were still limited in Taiwan. This study reviewed our experience about the technique evolution and outcome of using LDG for the patients with clinical stage (c-stage) I gastric cancers.

METHODS

A retrospective review of the patients undergoing LDG for c-stage I gastric cancers at a medical center of Taiwan was performed. The demographics, peri-operative parameters, reconstruction methods, morbidities, pathologic and oncological outcomes were analyzed.

RESULTS

A total of 100 patients with c-stage I gastric cancers between October 2005 and September 2016 were enrolled. Laparoscopy-assisted distal gastrectomy (LADG) was performed in the initial 69 cases. Total laparoscopic distal gastrectomy (TLDG) was done in the following 31 cases. There was no conversion of procedures, nor surgical mortality. The surgical morbidity rate was 13%, including 3 major complications. The ratio of using Billroth I reconstruction (83.9% versus 43.5%, p < 0.01) and the mean number of harvested lymph nodes (38.6 ± 14.8 versus 31.2 ± 15.2, p = 0.02) were both higher in the TLDG group than in the LADG group. The pathologic examination confirmed 78 patients were stage I, while 22 were stage II disease. Seven of the 24 patients with lymph node metastasis received adjuvant chemotherapy. Two patients had recurrence of diseases. The 3-year recurrence-free and overall survival were 93.3% and 95.8% separately.

CONCLUSION

These results suggested that laparoscopic gastrectomy could be performed safely and feasibly for patients with early gastric cancers. LADG is recommended for the establishment of the demanding technique.

Comparison of the short-term outcomes between delta-shaped anastomosis and conventional Billroth I anastomosis after laparoscopic distal gastrectomy: A meta-analysis

BACKGROUND

The conventional Billroth I anastomosis (cBIA) after laparoscopic distal gastrectomy (LDG) is performed through circular staple extracorporeally. Now, delta-shaped anastomosis (DA), which is performed using a linear stapler intracorporeally, becomes popular. We conducted a meta-analysis to compare the effectiveness and safety between the 2 techniques.

METHODS

A systematic literature search was performed using PubMed, Ovid, and the Cochrane Library Central. Participants of any age and sex, who underwent DA, or cBIA after LDG, were considered following inclusion criteria.

RESULTS

A total of 11 articles, published between 2010 and 2017, fulfilled the selection criteria. The total sample size of these studies was 2729 cases, including DA group 1008 cases and cBIA group 1721 cases. Compared to cBIA group, patients in DA group had less blood loss (mean deviation [MD] = -0.68, 95% confidence interval [CI] = -0.15 to -0.31, P < .001), fewer administration of analgesics (MD = -0.82, 95% CI = -1.58 to -0.05, P = .04), lower NRS score on POD 1 (MD = -0.84, 95% CI = -1.34 to -0.33, P = .001), lower NRS score on POD 3 (MD = -0.38, 95% CI = -0.50 to -0.26, P < .001). Furthermore, compared to cBIA group, obese patients in DA group had fewer total number of complications (MD = 0.46, 95% CI = 0.22 to 0.95, P = .04), shorter postoperative hospital stays (MD = -0.73, 95% CI = -1.18 to -0.28, P = .001), earlier first flatus (MD = -0.30, 95% CI = -0.50 to -0.10, P = .004), fewer administration of analgesics (MD = -1.08, 95% CI = -1.61 to -0.55, P < .001), lower NRS score on POD 1 (MD = -0.68, 95% CI = -0.99 to -0.37, P < .001) and lower NRS score on POD 3 (MD = -0.63, 95% CI = -0.86 to -0.40, P < .001).

CONCLUSIONS

Compared with cBIA, DA is a safe and feasible procedure, with similar surgical outcomes and postoperative complications. In terms of postoperative recovery, DA is less invasive with quicker resume than cBIA, especially for the obese patients.

Randomized controlled trial of uncut Roux-en-Y vs Billroth II reconstruction after distal gastrectomy for gastric cancer: Which technique is better for avoiding biliary reflux and gastritis?

AIM

To identify which technique is better for avoiding biliary reflux and gastritis between uncut Roux-en-Y and Billroth II reconstruction.

METHODS

A total of 158 patients who underwent laparoscopy-assisted distal gastrectomy for gastric cancer at the First Hospital of Jilin University (Changchun, China) between February 2015 and February 2016 were randomized into two groups: uncut Roux-en-Y (group U) and Billroth II group (group B). Postoperative complications and relevant clinical data were compared between the two groups.

RESULTS

According to the randomization table, each group included 79 patients. There was no significant difference in postoperative complications between groups U and B (7.6% vs 10.1%, P = 0.576). During the postoperative period, group U stomach pH values were lower than 7 and group B pH values were higher than 7. After 1 year of follow-up, group B presented a higher incidence of biliary reflux and alkaline gastritis. However, histopathology did not show a significant difference in gastritis diagnosis (P = 0.278), and the amount of residual food and gain of weight between the groups were also not significantly different. At 3 mo there was no evidence of partial recanalization of uncut staple line, but at 1 year the incidence was 13%.

CONCLUSION

Compared with Billroth II reconstruction, uncut Roux-en-Y reconstruction is secure and feasible, and can effectively reduce the incidence of alkaline reflux, residual gastritis, and heartburn. Despite the incidence of recanalization, uncut Roux-en-Y should be widely applied.

Subtotal Gastrectomy With Billroth II Anastomosis Is Associated With a Low Risk of Ischemic Stroke in Peptic Ulcer Disease Patients: A Nationwide Population-Based Study

Duodenal diversion can ameliorate lipid and glucose metabolism. We assessed the risk of stroke after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) in peptic ulcer disease (PUD). We identified 6425 patients who received SGBIIA for PUD between 1998 and 2010 from the Taiwan National Health Insurance Research Database as the study cohort; we frequency-matched them with 25,602 randomly selected controls from the PUD population who did not receive SGBIIA according to age, sex, index year, and comorbidities including hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and obesity. All patients were followed until the end of 2011 to determine the incidence of stroke. The incidence of stroke was lower in patients in the SGBIIA cohort than in those in the non-SGBIIA cohort (18.9 vs 22.9 per 1000 person-years, adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.72-0.89, P < 0.001). The risk of ischemic stroke (aHR 0.77, 95% CI 0.69-0.86, P < 0.001), rather than hemorrhagic stroke (aHR 1.00, 95% CI 0.78-1.28), was lower for the SGBIIA cohort than for the non-SGBIIA cohort according to the multivariable Cox proportional hazard regression analysis. The relative risk of ischemic stroke after SGBIIA was lower in men (aHR 0.77, 95% CI 0.69-0.86) than in women (aHR 0.80, 95% CI 0.65-0.99) and in patients aged ≥65 years (aHR 0.72, 95% CI 0.63-0.81) than in those of other age groups (≤49 years, aHR 0.82, 95% CI 0.48-1.39; 50-64 years, aHR 1.01, 95% CI 0.79-1.28). The relative risk of ischemic stroke after SGBIIA was also reduced in patients with comorbidities (aHR 0.84, 5% CI 0.75-0.95) rather than in those without comorbidities (aHR 0.81, 95% CI 0.59-1.12). SGBIIA is associated with a low risk of ischemic stroke for PUD patients, and its protective effect is prominent in men, patients aged ≥65 years, and those with comorbidities.

[Application of β-shaped intracorporeal Roux-en-y reconstruction in totally laparoscopic distal gastrectomy]

OBJECTIVE

To explore the technical feasibility, safety, and clinical efficacy of β-shaped Roux-en-Y reconstruction(β reconstruction) in totally laparoscopic distal gastrectomy (TLDG).

METHODS

Clinical data of 21 patients with gastric cancer undergoing TLDG with β reconstruction from January 2014 to May 2014 were retrospectively analyzed.

RESULTS

TLDG with β reconstruction was successfully performed in all the patients. The mean time of operation and β reconstruction was (229.0±18.7) min and (27.5±4.2) min. The blood loss was (91.0±38.3) ml and number of dissected lymph node was 33.2±4.6 per patient. The length of upper and lower segment of resection from lesion was (5.9±0.4) cm and (3.2±0.8) cm. The average time to resume fluid diet, time to restore flatus and hospital stay were (2.1±0.8) d, (3.1±0.9) d and (5.9±2.4) d, respectively.

CONCLUSION

The β reconstruction is a safe and feasible procedure for TLDG and provides satisfactory short-term efficacy.

Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls

BACKGROUND

A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes.

METHODS

We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics.

RESULTS

There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites.

CONCLUSION

Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.

Gastroduodenal intussusception due to gastric schwannoma treated by billroth II distal gastrectomy: One case report

Schwannomas are rarely observed in the gastrointestinal tract. The most common symptoms of a gastric schwannoma are abdominal pain or dyspepsia, gastrointestinal bleeding, and an abdominal mass. Many gastric schwannomas are asymptomatic and are discovered incidentally or at postmortem. The diagnosis of a schwannoma is based on immunohistochemical positivity for S-100 protein. We present a case report of a rare complication of gastric schwannoma causing gastroduodenal intussusception that was successfully managed by a Billroth II distal gastrectomy. In this rare case, the patient had intermittent, colicky abdominal pain, nausea, and vomiting for over 4 wk accompanied by a weight loss. A diagnosis of gastric intussusception was made by computed tomography. A Billroth II distal gastrectomy was then performed, and complete en bloc removal (R0 resection) was achieved. Pathology confirmed a gastric schwannoma through positive immunohistochemical staining for S-100 protein.

Subtotal gastrectomy for gastric cancer: long term outcomes of Billroth I reconstruction at a single European institute

BACKGROUND/AIMS

The role of Billroth I (BI) subtotal gastrectomy (SG) for gastric cancer (GC) remains controversial in Western countries. The aim of the study is to critically analyze the long term outcomes of this procedure in a large single-institution experience.

METHODOLOGY

Between 1990 and 2004, 158 patients underwent BI SG for GC at the Regina Elena Cancer Institute of Rome. Evaluation focused on cancer recurrence of the gastric stump, functional outcome and endoscopic findings.

RESULTS

Actuarial survival rate 10 years after resection in stage I-II was 70.7 per cent. After curative resection, primary cancer of the gastric stump occurred in one patient seven years after resection (0.7 per cent), whereas two patients had early recurrence (1.4 per cent) one and three years postoperatively. There were no oesophageal cancers. In survivors, Visick grades I and II achieved 95 per cent, and postoperative endoscopy showed no evidence of mucosal changes in 85 per cent of the patients. Twelve per cent of the patients took acid blocker regularly, however, the incidence of functional failure was 5 per cent.

CONCLUSIONS

In selected patients, Billroth I subtotal gastrectomy is a safe and effective procedure that provides long-term survival and very good functional outcome.

Safety and feasibility during the initial learning process of intracorporeal Billroth I (delta-shaped) anastomosis for laparoscopic distal gastrectomy

BACKGROUND

Intracorporeal Billroth I (ICBI) (delta-shaped) anastomosis is being increasingly used for laparoscopic distal gastrectomy. However, few studies have focused on the safety and feasibility of adopting this new technique. The present study aimed to review the surgical outcomes after the initial experience of performing ICBI anastomosis and to evaluate whether this technique can be safely adopted without increasing operative risk during the early learning process.

METHODS

Forty-two consecutive patients who underwent ICBI anastomosis with laparoscopic distal gastrectomy by a single surgeon were enrolled, and their operative outcomes and hospital course were compared with those of 179 patients who underwent conventional extracorporeal Billroth I (ECBI) anastomosis by the same operator. The learning curve was assessed by evaluating the moving average of anastomosis time.

RESULTS

The operating time in the ICBI group was significantly longer than that in the ECBI group (142 vs. 116 min, p < 0.001). However, there were no significant differences in the postoperative hospital course such as gas passage, diet initiation, postoperative fever, and hospital stay between the two groups. Postoperative morbidity did not significantly differ between the ICBI and ECBI groups (7.1 vs. 12.3 %, p = 0.428). No anastomosis-related complications occurred in the ICBI group. The mean anastomosis time for ICBI anastomosis was 24 ± 5 min, and the anastomosis average time curve showed that it reached a plateau approximately after the 14th case.

CONCLUSIONS

ICBI anastomosis has a steep learning curve without increasing operative risk in the early learning process, when performed by experienced laparoscopic surgeons. The technical feasibility and clinical advantages of intracorporeal anastomosis need to be proven in future clinical trials.

The effect of antecolic versus retrocolic reconstruction on delayed gastric emptying after classic non-pylorus-preserving pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) after pancreaticoduodenectomy increases length of hospital stay and costs, and may be influenced by surgical techniques.

METHODS

We retrospectively compared 400 patients with antecolic gastrojejunostomy with 400 patients with retrocolic gastrojejunostomy for the occurrence of DGE.

RESULTS

The prevalence of DGE was 15% in the antecolic group and 21% in the retrocolic group (P = .021), and median length of stay was shorter for the former (8 vs. 10 days, P = .001). The difference was statistically significant with grade A DGE (9% vs. 14%, P = .038), but not B or C. In a multivariate analysis, DGE was influenced by retrocolic reconstruction, as well as older age, chronic pancreatitis, preoperative bilirubin level, a history of previous upper abdominal surgery, and postoperative pancreatic fistula.

CONCLUSIONS

An antecolic gastrojejunostomy for classic non-pylorus-preserving pancreaticoduodenectomy is associated with a lower incidence of mild DGE (grade A) and a shorter length of stay.

Value of CT for ERCP Endoscopists to Identify the Type of Gastroenteric Anastomosis in Patients with Previous Subtotal Gastrectomy

Background/Aims: The aim of this study was to evaluate whether endoscopic retrograde cholangiopancreatography (ERCP) endoscopists can distinguish the type of gastroenteric anastomosis in patients with previous subtotal gastrectomy based on CT findings, particularly in biliary emergencies.

METHODOLOGY

A total of 70 abdominal CT scans from patients who had undergone gastrectomy (n = 36, Billroth I; n = 34, Billroth II) were enrolled. The shuffled images were reviewed by 3 ERCP endoscopists blinded to clinical data. The endoscopists were asked to provide the most probable type of anastomosis. The sensitivity, specificity and interobserver agreement were analyzed for identifying Billroth II gastrectomy.

RESULTS

The ERCP endoscopists were able to identify the type of anastomosis based on CT findings with a sensitivity, specificity and interobserver agreement of 100%, 97.2%, and 0.98, respectively. The key CT features for distinguishing Billroth II gastrectomy from Billroth I gastrectomy were: i) loss of continuity between the remnant stomach and duodenum; ii) less distended duodenal bulb; iii) the presence of a closed duodenal stump with surgical staples and iv) the presence of continuity between the remnant stomach and the jejunum.

CONCLUSIONS

ERCP endoscopists were able to use CT findings to distinguish the type of gastroenteric anastomosis in patients with previous gastrectomy.

[Feasibility of delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer]

OBJECTIVE

To investigate the feasibility of delta-shaped (DS) gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer.

METHODS

From July 2013 to November 2013, 22 gastric cancer patients underwent DS gastroduodenostomy using laparoscopic linear stapler. All the patients underwent TLDG with D2 lymphadenectomy. In addition, modified DS anastomosis (when closing the common entry hole, previous duodenal staple line was also removed) was used in selected patients. Clinical data of these 22 patients were retrospectively analyzed.

RESULTS

All the patients underwent TLDG with D2 lymphadenectomy and DS gastroduodenostomy. Among them, 12 patients underwent modified DS anastomosis. The total operative time was (194.6±38.4) min, and the DS anastomosis time was (19.1±14.1) min. The number of linear stapler cartridges used per patient was 5.8±0.8. The intraoperative blood loss was (49.5±24.0) ml. The number of lymph nodes harvested per patient was 32.8±12.4. All the patients achieved microscopic cancer-free resection margin. The time to the first postoperative flatus, first water intake, and semi-liquid diet was (2.9±0.7) d, (4.8±1.1) d, and (6.6±1.2) d, respectively. The duration of postoperative hospital stay was (10.1±2.3) d. The postoperative complication rate was 9.1% (2/22). No patients developed anastomosis-related complications including anastomotic leakage, stenosis, or bleeding.

CONCLUSIONS

Delta-shaped gastroduodenostomy is simple, easy, safe, and feasible. It will be an ideal choice for reconstruction after totally laparoscopic distal gastrectomy, and has great value in clinical practice.

ERCP for patients who have undergone Billroth II gastroenterostomy and Braun anastomosis

Endoscopic retrograde cholangiopancreatography (ERCP) is efficacious in patients who have undergone Billroth II gastroenterostomies, but the success rate decreases in patients who also have experienced Braun anastomoses. There are currently no reports describing the preferred enterography route for cannulation in these patients. We first review the patient’s previous surgery records, which most often indicate that the efferent loop is at the greater curvature of the stomach. We recommend extending the duodenoscope along the greater curvature of the stomach and then advancing it through the “lower entrance” at the site of the gastrojejunal anastomosis, along the efferent loop, and through the “middle entrance” at the site of the Braun anastomosis to reach the papilla of Vater. Ten patients who had each undergone Billroth II gastroenterostomy and Braun anastomosis between January 2009 and December 2011 were included in our study. The overall success rate of enterography was 90% for the patients who had undergone Billroth II gastroenterostomy and Braun anastomosis, and the therapeutic success rate was 80%. We believe that this enterography route for ERCP is optimal for a patient who has had Billroth II gastroenterostomy and Braun anastomosis and helps to increase the success rate of the procedure.

[State of duodenal patency in patients with postgastrectomy syndromes]

It was analyzed the examination and treatment results of 100 patients who underwent resection of stomach by Billroth-I in case of peptic ulcer. Chronic disorders of duodenal patency were diagnosed in 86% of patients. The main role of chronic disorders of duodenal patency in postgastrectomy syndromes development was proved. There were a combination of reflux gastritis with dumping syndrome in 66.3% of patients, a combination of reflux gastritis with recurrent ulcer in 8.1% of patients. Correction of chronic disorders of duodenal patency is necessary stage in conservative and surgical treatment of postgastrectomy syndromes.

Gastric remnant cancer patients had a better prognosis than upper-third gastric cancer patients in a case-control study after surgical treatment

BACKGROUND

The aim was to compare the clinicopathological features and prognostic outcomes of gastric remnant carcinoma patients with those of patients with upper-third gastric cancer.

METHODS

Clinical data extracted from 112 gastric remnant carcinomas and 367 upper-third gastric cancer patients were analyzed to explore the clinicopathologic differences between two groups. After radical resection, prognostic difference between them was evaluated through a 1:2 matched case-control study.

RESULTS

The pattern of gastric remnant carcinomas showed a male predominance. Undifferentiated type histology, depth at T4 stage and distant metastases were more frequent in gastric remnant carcinomas than in upper-third gastric cancers (P <0.05). The radical resectability of gastric remnant carcinomas was lower and the multi-visceral resectabilitiy was relatively higher than the other group (P = 0.00). Gastric remnant carcinomas trended to have a higher incidence of metastases to either mesojejunum or lower mediastinal lymph nodes than upper-third gastric cancers, but patient survival was not significantly different. In the case-control study, gastric remnant carcinomas had a better prognosis than upper-third gastric cancers after radical resection when the clinicopathologic features and surgical treatment were matched.

CONCLUSIONS

Although there was no significant prognostic distinction between gastric remnant carcinomas and upper-third gastric cancer, after radical surgical treatment, patients with the former had an even better prognosis.