Gastric Resection Research Articles

A137 LAPAROSCOPIC ENDOSCOPIC COOPERATIVE SURGERY FOR GASTROINTESTINAL STROMAL TUMOURS: EARLY EXPERIENCE IN A CANADIAN ACADEMIC CENTRE

Abstract Background Surgical resection with laparoscopic gastric wedge resection is commonly conducted for local management of gastrointestinal stromal tumours (GIST). However, resection margins are often difficult to appreciate for lesions with larger endophytic components. As a result, tumour margins may be compromised or excess tissue resected. Laparoscopic endoscopic cooperative surgery (LECS) was developed in Japan to overcome these technical challenges in the resection of subepithelial lesions, including GISTs. Here, we present a case report of an early Canadian experience utilizing LECS in the management of gastric GIST. Aims To describe a case report of an early Canadian experience of LECS for the resection of a gastric GIST. Methods We performed a review of the literature and describe a case of LECS. Results We present a 70-year-old female referred to our centre for endoscopic resection of a 2.5x2.5cm histologically confirmed gastric GIST (low mitotic index and no known metastases). Repeat endoscopic evaluation at our centre confirmed a 25-30mm subepithelial lesion with both exophytic (small) and endophytic (large) components. After tumour board review, we opted for a LECS approach. In the OR, the lesion was identified endoscopically and marked with a Dual J-Knife (Olympus). The margins were injected with a combination of Voluven, methylene blue, and dilute epinephrine. A circumferential incision was then completed using standard ESD technique. The lesion was subsequently identified laparoscopically, with endoscopic guidance, along the lesser curvature. The lesser omentum was mobilized for clear visualization of the serosa around the lesion. A full thickness incision was made endoscopically along the distal aspect of lesion. Full thickness resection was continued endoscopically for one third of the circumference of the lesion until gastric insufflation became compromised. Full thickness resection was completed laparoscopically under endoscopic guidance with grossly negative margins. The defect was closed with running laparoscopic sutures. Endoscopic leak test was performed which was negative. The specimen was retrieved and follow up pathology demonstrated a GIST with low mitotic index and negative margins without tumour rupture. Conclusions In a review of the literature, LECS appears to minimize tissue resection while maintaining R0 resection rates. This technique is especially useful for subepithelial lesions with larger endophytic and transmural components. It has an excellent safety profile with a less than 5% anastomotic leak rate. As such, the literature supports LECS as a suitable procedure for gastric subepithelial lesions <50 mm. However, further studies are needed to compare it systematically to conventional laparoscopic wedge resection in addition to other innovative endoscopic techniques such as STER and EFTR. Funding Agencies None

A126 GIST – GLUE IN STROMAL TUMOR

Abstract Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and typically located in the stomach. Gastrointestinal bleeding is a frequent complication of GISTs with surgery being the treatment of choice. Managing GIST bleeding endoscopically can be challenging by an underlying friable neovascularization. The use of cyanoacrylate basis glue has well-established utility in the endoscopic management of variceal bleeding. However, the role of cyanoacrylate basis glue in the management of GIST bleeding is exceptionally rare. Aims We present a case of a bleeding GIST that was successfully managed through the utilization of cyanoacrylate basis glue allowing for elective surgical resection. Methods A chart review was undertaken. Also, a literature review of the topic was also conducted using the terms “GIST, Cyanoacrylate Glue, Bleeding” Results A 75-year-old male presented with a four week history of exertional chest pain. He had noticed persistent black stools for the previous two weeks. His past medical history was relevant for coronary artery disease; two years earlier he had drug eluting stents placed. His medications included ASA 81mg PO OD and Pantoprazole 40mg OD. Physical examination revealed stable vital signs, a soft abdomen and melena on rectal examination. Laboratory investigations showed a hemoglobin of 75 g/L, and 2 weeks prior his hemoglobin had been 120 g/L. Platelets were 149. His liver enzymes and liver function tests were unremarkable. His BUN was 9.9 mmol/L and creatinine of 96.0 umol/L. An esophagogastroduodenoscopy (EGD) revealed a 5cm smooth mass with a central deep depression, in the antrum, that was actively bleeding. Attempts to clip were unsuccessful due to the width of the central depression which was the source of bleeding. (See image 1). The endoscopist chose to inject 1cc of cyanoacrylate basis glue directly into the bleeding site. A subsequent CT scan revealed a 5.2cm polypoid mass in the gastric antrum, favored to be a GIST with no evidence of metastatic disease. Surgery and Cardiology were involved in the care of this patient, and emergency surgery was delayed due to the patient having an intercurrent acute coronary syndrome. Post EGD, the patient underwent an angiogram and the culprit coronary artery was stented and patient was started on dual antiplatelet therapy. Patient then successfully underwent a laparoscopic gastric wedge resection for his GIST, this was completed 1 week after EGD. The pathology of the resected area was in keeping with a GIST. Of note, the patient’s hemoglobin had been stable from the time of EGD until surgical intervention. Conclusions Managing GIST bleeding endoscopically can be challenging, and surgical resection is the recommended treatment modality. In situations where surgical intervention is contraindicated, endoscopic therapy with cyanoacrylate basis glue can be considered to achieve hemostasis in GIST bleeding. Funding Agencies None

Laparoendoscopic resection of a tumor of the gastroesophageal junction

Atypical gastric resection has proved to be beneficial to treat submucosal tumors. The technique is more difficult when these tumors develop next to the gastroesophageal junction (GEJ). Intragastric resection combining endoscopic and laparoscopic approach was proposed to solve this limitation. There are no publications about this technique in our environment. A 42-year-old female patients with a 2-mm subepithelial tumor below the cardia evaluated by upper gastrointestinal (UGI) videoendoscopy and endoscopic ultrasound suggestive of a gastrointestinal stroma tumor (GIST) underwent resection using the combined laparo-endoscopic approach. Under laparoscopic guidance, balloon-tipped trocars were introduced in the abdominal cavity and then into the stomach using endoscopic view. The balloons were inflated to fix the gastirc wall to the abdominal wall. The lesion was resected using mechanical stapler. The combined approach is safe and efficient, and simple to perform for trained professionals, constituting a reproducible option in selected cases

Laparoscopic intragastric resection of gastric synovial sarcoma: report of the first ever case with video demonstration

BackgroundSynovial sarcoma (SS) is a rare soft tissue tumor. Among different anatomical locations where it can be found, gastric localization is a very uncommon one. Based on soft tissue sarcoma guidelines, complete tumor excision is considered the main treatment approach. Depending on size and localization of the tumor, both wedge and major gastric resections have been performed in the past for the treatment of this condition.Case presentationWe present the case of a 43-year-old woman who underwent a laparoscopic intragastric excision of a gastric 10-mm SS located nearby the esophagogastric junction. Pathology examination confirmed the presence of a SS. The resected specimen confirmed margin-free excision of a monophasic spindle cell neoplasm invading the submucosa and presenting the rearrangement of SS18 gene at fluorescence in situ hybridization (FISH). No adjuvant treatment was offered, and 18 months after surgery, the patient was alive and disease free.ConclusionsThis represents the first case reported in literature of a laparoscopic intragastric resection for a gastric SS. This approach allowed to obtain a full thickness radical tumor resection with the advantages of minimally invasive and organ preserving surgery.

Comparison of open and laparoscopic gastrectomy for gastric cancer: a low volume center experience.

In gastric cancer, laparoscopic gastrectomy is commonly performed in Asian countries. In other regions where tumor incidence is relatively low and patient characteristics are different, developments in this issue have been limited. In this study, we aimed to compare the early results for patients who underwent open or laparoscopic gastrectomy for gastric cancer in a low volume center. We retrospectively analyzed the data of patients who underwent curative gastric resection (open gastrectomy n: 30; laparoscopic gastrectomy n: 30) by the same surgical team between 2014 and 2019. The tumor was localized in 60% (36/60) of the patients in the proximal and middle 1/3 stomach. In laparoscopic gastrectomy group, the operation time was significantly longer (median, 297.5 vs 180 minutes; p <0.05). In open gastrectomy group, intraoperative blood loss (median 50 vs 150 ml; p <0.05) was significantly higher. Tumor negative surgical margin was achieved in all cases. Although the mean number of lymph nodes harvested in laparoscopic gastrectomy group was higher than the open surgery group, the difference was not statistically significant (28.2 ± 11.48 vs 25.8 ± 9.78, respectively; p= 0.394). The rate of major complications (Clavien-Dindo ≥ grade 3) was less common in the laparoscopic group (6.7% vs 16.7%; p= 0.642). Mortality was observed in four patients (2 patients open, 2 patients laparoscopic). In low-volume centers with advanced laparoscopic surgery experience, laparoscopic gastrectomy for gastric cancer can be performed with the risk of morbidity-mortality similar to open gastrectomy.

Safety and efficacy of adjuvant chemotherapy with oxaliplatin and S-1 for patients with locally advanced gastric cancer after D2 lymph nodes dissection

Objective: To investigate the safety and efficacy of oxaliplatin combined with S-1 (SOX) as adjuvant chemotherapy after D2 radical gastrectomy for locally advanced gastric cancer. Methods: A descriptive case series study was applied. Case inclusion criteria: (1) locally advanced gastric cancer confirmed by endoscopic biopsy or surgical specimen pathology as gastric adenocarcinoma; (2) receiving D2 radical gastric resection followed by SOX regimen adjuvant chemotherapy. Case exclusion criteria: (1) postoperative pathological TNM stage I or IV; (2) acute complications and emergency surgeries; (3) receiving neoadjuvant therapy; (4) concurrent malignancies and complications compromising patients' treatment or survival; (5) without receiving adjuvant SOX chemotherapy. A total of 94 patients with stage II-III gastric cancer who underwent D2 radical gastrectomy and postoperative adjuvant SOX chemotherapy at department of Gastrointestinal Surgery, Peking University People's Hospital from January 2014 to December 2019 were retrospectively enrolled. Chemotherapy-related adverse events, overall survival (OS) and progression-free survival (PFS) were analyzed. Kaplan-Meier survival analysis was performed and log rank test was used to analyze the difference between groups. P<0.2 or clinically significant indicators in univariate analysis were included in Cox regression model for multivariate survival analysis. Results: Among these 94 patients, there were 65 males and 29 females with an average age of (58.2±12.1) years; 33 patients with hypertension, diabetes mellitus, or cardiovascular and cerebrovascular diseases, 11 patients with family history of gastrointestinal tumors; 59 patients with tumors locating in the antrum or pylorus, 16 patients in the gastric body, 19 patients in the gastric fundus or cardia; 29 patients underwent total gastrectomy, 5 patients underwent proximal subtotal gastrectomy, and 60 patients underwent distal subtotal gastrectomy. In this study, 73 patients (77.7%) completed at least 5 cycles of adjuvant SOX regimen chemotherapy. Grade 3-4 adverse reactions included thrombocytopenia (23.4%, 22/94), nausea and vomiting (18.1%, 17/94) and peripheral neurotoxicity (6.4%, 6/94). Eighty-nine patients (94.7%) completed follow-up with a median follow-up time of 32 months. The 3-year and 5-year OS rates were 89.8% and 83.7%, respectively, and the 3-year and 5-year PFS rates were 81.4% and 78.1%, respectively. Taking 5 chemotherapy cycles as the cut-off point, the 3-year OS rate and 3-year PFS rate were 72.2% and 53.9% in the adjuvant chemotherapy < 5 cycles group, and 93.7% and 87.1% in the adjuvant chemotherapy ≥5 cycles group, respectively; the differences were statistically significant (P=0.029, P=0.006). Univariate analysis showed that the adjuvant chemotherapy < 5 cycles group was associated with worse 3-year OS (P=0.029). Multivariate analysis showed that insufficient chemotherapy cycle (HR=9.419, 95% CI: 2.330-38.007, P=0.002) was an independent risk factor for 3-year OS. Meanwhile, univariate analysis showed that the adjuvant chemotherapy <5 cycles (P=0.006), preoperative CEA > 4.70 μg/L (P=0.035) and adjacent organ resection (P=0.024) were associated with worse 3-year PFS. Multivariate analysis showed that adjuvant chemotherapy <5 cycles (HR=10.493, 95% CI: 2.466-44.655, P=0.001) and adjacent organ resection (HR=127.518, 95% CI: 8.885-1 830.136, P<0.001) were independent risk factors for 3-year PFS. Conclusions: Oxaliplatin combined with S-1 as an adjuvant chemotherapy regimen for locally advanced gastric cancer has high efficacy and low incidence of adverse reactions. At least 5 cycles of SOX regimen adjuvant chemotherapy can significantly improve prognosis of patients with stage II-III gastric cancer.

Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009-2017).

For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection-especially in the western hemisphere-are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany. All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I-V in ascending caseload order). Postoperative deaths and failure to rescue were determined. Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39-0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload. Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.

Nutritional status predicts clinical outcomes in patients with gastric cancer undergoing radical gastrectomy

Objective: To evaluate the effect of nutritional status on clinical and pathological data for stage Ⅰ-Ⅳ gastric cancer patients from the cancer survival investigation information. Methods: A database of 302 consecutive gastric cancer patients underwent radical gastrectomy was enrolled in this study. The clinical and pathological information of them were corrected and the relationship between the nutritional index and the patients survival time were analyzed by a Cox regression model. Results: The clinical data analysis of 302 patients with gastric cancer who received total gastric resection indicated that the nutritional status was related to the stage of tumor patients, suggesting that the later the stage was, the more necessary the nutritional therapy intervention was. Univariate analysis showed that Ⅲ+Ⅳ of TNM staging (HR=4.417, 95%CI:2.483-6.351; P =0.029), patient age of 65 and above (HR=2.217, 95%CI:0.522-3.912; P =0.038), lymph node metastasis positive (HR=2.517, 95%CI:0.516-4.518; P=0.036), poor tumor differentiation (HR=3.626, 95%CI:0.721-6.531; P =0.021) and low PNI (HR=2.612, 95%CI: 0.712-4.512; P =0.029) is an important risk factor for poor prognosis. In the multivariate analysis, Ⅲ+Ⅳ of TNM staging (HR=3.821, 95%CI:1.923-5.719; P =0.014), patient age of 65 and above (HR=1.168, 95%CI:0.321-2.015; P =0.036) and low PNI (HR=2.435, 95%CI:1.024-3.846; P =0.039) was independently correlated with poor survival time; When age was used as a stratification factor, the correlation between CONUT recurrence and survival in patients with gastric cancer ≥65 years old after total gastric resection was analyzed and compared. For disease-free survival, the CONUT high group (>3) was 25.2 months, while the CONUT low group (≤3) was 30.9 months, (χ2=3.763,P=0.029), showing a significant difference. For the overall survival, the CONUT high(>3) group was 30.3 months, compared with the CONUT low(≤3) group at 34.5 months, (χ2=4.924,P=0.042), and the difference was also statistically significant. Conclusions: High controlling nutritional status is an independent risk factor associated with poor gastric cancer survival and it is an independent risk factor in predicting overall survival (OS) in elderly (≥65) gastric cancer after radical gastrectomy.

The Surgical Legacy of Randolph Lee Clark, Jr, MD: First Director and Surgeon-in-Chief of University of Texas MD Anderson Cancer Center II. Surgical Practice and Leadership at University of Texas MD Anderson Cancer Center (1946-1978).

Dr. R. Lee Clark Jr brought a broad-based cancer surgery experience to MD Anderson Hospital for Cancer Research when he became its first Surgeon-in-Chief and full-time salaried physician in 1946. He performed major surgery until 1971 including major head and neck operations, thyroidectomy, mastectomy, radical melanoma and sarcoma surgery, gastric and abdominal-perineal resection, and even hemipelvectomy. He initiated major programs in radiation therapy and mammography breast screening, and organized teams of specialists in a group practice providing multidisciplinary cancer care. Dr. Clark was elected into membership by the James Ewing Society (currently the Society of Surgical Oncology), the Southern Surgical Association, and the American Surgical Association, and was a founding member of the Society of Head and Neck Surgery. The Society of Surgical Oncology honored him with the Lucy Wortham James Award in 1965 and the James Ewing Lecture Award in 1977. Dr. Clark also provided invaluable leadership in the American College of Surgeons, leading a fledgling Committee on Cancer into a robust organization that became the Commission on Cancer. The College of Surgeons honored him with their Distinguished Service Award in 1969. Dr. Clark recruited major surgical leaders and personally designed the new hospital that opened in 1954, described in Time magazine as "the most modern, most ingeniously designed hospital in the U.S." R. Lee Clark, Jr. was an accomplished and busy clinical surgeon, a visionary and charismatic leader, and an organizational genius. Indeed, he was one of the first pioneers in the specialty of surgical oncology.

Current status of function-preserving gastrectomy for gastric cancer.

Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is “function‐preserving gastrectomy (FPG).” FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long‐term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper‐third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus‐preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle‐third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.

Reconstruction following gastrectomy

Minimally invasive surgical techniques with respect to the treatment of gastric cancer have progressed rapidly over the last few years. Especially in Asia, where the incidence of gastric cancer is ten times higher than in Europe, surgery for gastric cancer is steadily evolving, especially regarding laparoscopic and robot-assisted procedures. This review first discusses the different options for reconstruction of the gastrointestinal passage after gastrectomy, ranging from Billroth procedures to the latest developments, such as the double tract reconstruction. In particular, the possibility of function-preserving partial gastrectomy, such as proximal and distal gastric resection and the corresponding reconstruction techniques are presented. The latest studies and technical developments are presented, especially with respect to laparoscopically assisted, completely laparoscopic and robot-assisted gastrectomies.

Absence of the celiac trunk and anomalous very low origin of the common hepatic artery arising independently from the abdominal aorta just above aortic bifurcation in patient undergoing radical pancreaticoduodenectomy

PurposeKnowledge of anomalies of the celiac trunk is very important during various surgical procedures (such as pancreatic and gastric resections including Appleby operation, liver resections and liver transplantations) and as well as radiologic procedures (such as chemoembolization of pancreatic and hepatic tumors).MethodsA 77-years-old woman was admitted to our department for surgical treatment of ampullary adenocarcinoma G2 confirmed in endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and ampullary biopsy. In the contrast-enhanced computed tomography, the ampullary tumor was not visible, but the main pancreatic duct within pancreatic head and isthmus was dilated (indirect radiological tumor signs). An absence of the celiac trunk (CT) was established via computed tomography. Therefore, computed tomography-based angiography (angio-CT) of the abdominal aorta (AA) was performed before operation.ResultsAngio-CT confirmed an extremely rare vascular anomaly: an absence of CT. The left gastric (LGA), splenic (SA), and common hepatic (CHA) arteries connected above origin of the superior mesenteric artery (SMA) from the AA. Pylorus-preserving pancreaticoduodenectomy (PD) was performed. This anomaly was also confirmed intraoperatively. The postoperative course was uneventful and the patient was discharged on postoperative day 10. There were no signs of recurrence of the tumor during the 6 months follow-up.ConclusionThe proper preoperative identification of anomalies within major abdominal vessels and its relationship to the tumor is very important to avoid intraoperative vascular injury and major postoperative complications.

Impact of Gastric Resection and Enteric Anastomotic Configuration on Delayed Gastric Emptying after Pancreaticoduodenectomy: A Network Meta-analysis of Randomized Trials

Purpose: Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several randomised controlled trials (RCTs) have explored operative strategies to minimise DGE, however, the optimal combination of gastric resection approach, anastomotic route, and configuration, role of Braun enteroenterostomy remains unclear. Methods: MEDLINE, Embase, and CENTRAL databases were systematically searched for RCTs comparing gastric resection (Classic Whipple, pylorus-resecting, and pylorus-preserving), anastomotic route (antecolic vs retrocolic) and configuration (Billroth II vs Roux-en-Y), and enteroenterostomy (Braun vs no Braun). A random-effects Bayesian network meta-analysis was conducted to determine the optimal combination of approaches to PD for minimising DGE. Results: Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6% (n = 647). Pylorus-resecting, antecolic, Billroth II with Braun was associated with the lowest rates of DGE and ranked the best in 35% of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32% of comparisons. Pairwise meta-analysis of retrocolic vs antecolic route of gastro-jejunostomy found increased risk of DGE with the retrocolic route (OR 2.1, 95% CrI; 0.92 - 4.7). Pairwise meta-analysis of Braun found a trend towards lower DGE rates with Braun compared to no Braun (OR 1.9, 95% CrI; 0.92 - 3.9). Having a Braun ranked the best in 96% of comparisons. Conclusion: Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy may be associated with the lowest rates of DGE.

Diagnosis and management of gastrointestinal chemical burns and post-burn oesophageal stenosis.

Post-burn oesophageal stenosis occurs as a result of accidental or intentional ingestion of a corrosive substance. Global estimates indicate tens of thousands of acid or lye ingestion cases per year. In some cases patients in the early post-burn phase require urgent surgical intervention. Endoscopy, along with chest and abdominal computed tomography, form the basis of diagnosis. The need for emergency oesophageal or gastric resection is associated with a high mortality rate of up to 60%. Post-burn oesophageal stenosis is a challenging clinical problem that requires coordinated multispecialty treatment. The treatment of post-burn stenosis may be with endoscopic techniques or reconstructive surgery. Surgical reconstruction is performed once the scar has definitively formed. The extent of the injury, anatomical conditions, previous surgery and the team’s expertise determine the optimum reconstructive method. In this article, we present the current knowledge on the diagnosis and treatment of oesophageal burns.

Advances in the surgical management of gastric and gastroesophageal junction cancer.

Since Theodore Billroth and Cesar Roux perfected the methods of post-gastrectomy reconstruction in the late 19th century, surgical management of gastric and gastroesophageal cancer has made incremental progress. The majority of patients with localized disease are treated with perioperative combination chemotherapy or neoadjuvant chemoradiation. Staging laparoscopy before initiation of treatment or before surgical resection has improved staging accuracy and can drastically inform treatment decisions. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer appears to have settled in favor of D2 dissection with the recently published 15-year follow-up of the Dutch randomized trial. Minimally invasive gastric and gastroesophageal resections are performed routinely in most centers affording faster recovery and equivalent oncologic outcomes. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers, while randomized data on its oncologic adequacy are pending. Multi-visceral resections and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has been utilized selectively for patients with locally advanced tumors who have demonstrated disease control on preoperative chemotherapy. This review summarizes the current standard of surgical care for gastroesophageal junction and gastric cancer as well as highlights recent and upcoming advances to the field.

Experience of synchronous thoracic and gastric carcinoma resection: a case report

Experience of synchronous thoracic and gastric carcinoma resection: a case report

Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach.

Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor.Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital.Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation.Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.

Management of anatomical challenges during laparoscopic cephalic duodenopancreatectomies

Introduction: Laparoscopic cephalic duodenopancreatectomy (LCDP) is considered a surgery of high technical complexity. It has a long learning curve because of the need of high laparoscopic technical skills, especially in the presence of anatomical variations. The aim of this video is to present three cases of LDCP (pure and hybrid) with difficult anatomical challenges and how to approach them. Case 1: A 76 years old woman presents with painless jaundice and workup reveals an infiltrating 20 mm adenocarcinoma of the Vater´s ampulla. During LCDP, a right posterior bile duct draining independently distal to the common bile duct is found, so two-separated laparoscopic bilio-enteric anastomosis are performed. Case 2: A 70 years old men presents with painless jaundice and workup reveals a 30 mm dysplastic adenoma of the Vater´s ampulla. He had a surgical history of an open gastric antral resection due to a perforated peptic ulcer 40 years ago. During LCDP, multiple lysis adhesions of the hepatic hilium are required and a right hepatic artery arising from the superior mesenteric artery is identified and preserved. Case 3: A 70 years old men with Child-B cirrhosis presents with jaundice and workup reveals an adenocarcinoma of the Vater´s ampulla not suitable for endoscopic resection. Hepatic venous gradient pressure (HVGP) measurement is 7 mmHg, so after multidisciplinary discussion a hybrid LCDP is performed with no complications. Conclusion: anatomical challenges can be safely approached under laparoscopic surgery during LCDP.

Gastrointestinal exposed endoscopic full-thickness resection in the era of endoscopic suturing: a retrospective single-center case series.

IntroductionExposed endoscopic full thickness resection (EFTR) is a minimally invasive technique that has shown promising efficacy and safety in the removal of both gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable for conventional resection techniques. Given the chance of realizing endosurgical full-thickness suturing, the Endoscopic Suturing System (ESS) can be used to close wall defects in this setting. However, data concerning its use in EFTR are still limited.AimThis study was conducted to evaluate the safety and efficacy of exposed EFTR with defect closure using the ESS for the removal of both GI SMTs and select ETs unsuitable for conventional resection techniques.Material and methodsThis was a retrospective, single-center, observational cohort study of patients who underwent GI exposed EFTR.ResultsSeven patients (M : F 6 : 1) with a mean age of 56 ±14.5 years were identified. The indications were MP-originating SMTs of the stomach (n = 2) and duodenum (n = 2), and from submucosa of the rectum (n = 1), and 2 ETs of the rectum. Exposed EFTR and defect closure were successfully performed in 6/7 patients. One case was converted to laparoscopic gastric wedge resection due to technical unfeasibility. We performed an R0 resection in all cases, with the exception of 1 case of rectal EFTR. No macroscopic recurrence was detected at 6-month endoscopic follow-up.ConclusionsGI exposed EFTR with defect closure by the ESS appears to be feasible, effective, and safe in referral centers. Further studies are necessary to clarify the role of the ESS for post-EFTR wall defect closure.

ПРИМЕНЕНИЕ ТЕСТА УТЕЧКИ КРАСИТЕЛЯ ДЛЯ КОНТРОЛЯ ГЕРМЕТИЧНОСТИ ЖЕЛУДОЧНО-КИШЕЧНОГО ТРАКТА ПРИ БАРИАТРИЧЕСКИХ ОПЕРАЦИЯХ

The problem of obesity is widespread both in the Republic of Belarus and on a global scale. So, according to the WHO, 640 million people in the world suffer from obesity [6]. In the Republic of Belarus in 2015—2016.rasprostranennost' ozhireniya sredi vzroslogo naseleniya sostavlyala 24,5 % [5, 6]. Morbidnoye ozhireniye pri IMT &gt;40 kg/m2, ili &gt;35 kg/m2 pri nalichii soputstvuyushchey patologii, chasto okazyvayetsya refrakternym k konservativnym the prevalence of obesity among the adult population was 24.5 % [5, 6]. Morbid obesity with a BMI &gt;40 kg/m2, or &gt;35 kg/m2 in the presence of concomitant pathology, is often weight loss in patients is precisely surgical intervention [2]. Among the performed bariatric operations, interventions involving gastric resection or bypass surgery prevail. Thus, in the world, the share of gastric bypass surgery on a Roux-type loop is 41.9 %, sleeve gastrectomy is 32.6 %, and the share of mini-gastric bypass is 5.0 % [6]. One of the most common complications after the listed bariatric procedures is the failure of the gastric suture line or anastomoses. After gastric sleeve gastrectomy, the incidence of this complication reaches 3.9 %, and after Roux-en-Y loop gastric bypass surgery — up to 8 % [3,7]