Gastric Resection Research Articles

Prophylactic surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC CO2) versus standard surgery for gastric carcinoma at high risk of peritoneal carcinomatosis: short and long-term outcomes (GOETH STUDY)—a collaborative randomized controlled trial by ACOI, FONDAZIONE AIOM, SIC, SICE, and SICO

IntroductionAt the time of diagnosis, 15–20% of gastric carcinomas are in stage T4 or T4b. Furthermore, 5–20% of patients undergoing potentially curative surgery suffer from synchronous or metachronous peritoneal metastases. To date, neither surgery nor systemic chemotherapy successfully controls peritoneal dissemination, offering a limited impact on survival. Peritoneal metastases are in fact responsible for death in around 60% of gastric cancer patients.Several Eastern studies in the past have focused on hyperthermic intraperitoneal chemotherapy (HIPEC) as a prophylactic measure in patients with serosal extension, nodal involvement, and positive peritoneal fluid cytology. Therefore, a new multimodal therapeutic strategy based on aggressive surgery plus new locoregional treatment may prolong survival in this particular clinical scenario.MethodsThis study compares the efficacy of prophylactic surgery (radical gastric resection, appendectomy, resection of the round ligament of the liver, and bilateral adnexectomy) plus hybrid CO2 HIPEC system versus standard surgery in patients with T3-T4 N0-N + gastric adenocarcinoma. Patients will be randomly assigned (1:1 ratio) to the experimental arm or standard surgery. The primary endpoint is to establish the difference in disease-free survival between the groups. The secondary objective is to compare the safety and tolerability of prophylactic surgery plus HIPEC CO2 versus standard surgery.DiscussionConsidering the poor prognosis of patients with peritoneal dissemination from gastric cancer, a prophylactic strategy to prevent peritoneal metastases may be beneficial. In patients with gastric cancer at high risk of peritoneal carcinomatosis, we propose aggressive surgical treatment with radical gastrectomy, removal of organs at risk of harbouring tumour cells, and HIPEC.Trial registrationClinicalTrials.gov NCT03917173. Registered on 16 April 2019.Protocol version: v1, March 27, 2019.Protocol number: IRFMN-GCC-7813.EudraCT number: 2019–001478-27.

Gastrectomy for cancer beyond life expectancy. A comprehensive analysis of oncological gastric surgery in Germany between 2008 and 2018.

Major gastric surgery for distal esophageal and gastric cancer has a strong impact on the quality of life, morbidity, and mortality. Especially in elderly patients reaching their life expectancy, the responsible use and extent of gastrectomy are imperative to achieve a balance between harm and benefit. In the present study, the reimbursement database (German Diagnosis Related Groups (G-DRG) database) of the Statistical Office of the Federal Republic of Germany was queried to evaluate the morbidity and mortality of patients aged above or below 75 years following gastrectomy. All patients in Germany undergoing subtotal gastrectomy (ST), total gastrectomy (T), or gastrectomy combined with esophagectomy (TE) for gastric or distal esophageal cancer (International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) C15.2, C15.5, and C16.0-C16.9) between 2008 and 2018 were included. Intraoperative and postoperative complications as well as comorbidities, in-hospital mortality, and the extent of surgery were assessed by evaluating ICD-10 and operation and procedure key (Operationen- und Prozedurenschlüssel) codes. A total of 67,389 patients underwent oncologic gastric resection in Germany between 2008 and 2018. In total, 21,794 patients received ST, 41,825 received T, and 3,466 received TE, respectively. In 304 cases, the combinations of these, in fact, mutually exclusive procedures were encoded. The proportion of patients aged 75 years or older was 51.4% (n = 11,207) for ST, 32.6% (n = 13,617) for T, and 28.1% (n = 973) for TE. The in-hospital mortality of elderly patients was significantly increased in all three groups. (p < 0.0001) General complications such as respiratory failure (p = 0.0054), acute renal failure (p < 0.0001), acute myocardial failure (p < 0.0001), and the need for resuscitation (ST/T: p < 0.0001/TE: p = 0.0218) were significantly increased after any kind of gastrectomy. Roux-en Y was the most commonly applied reconstruction technique in both young and elderly patients. Regarding lymphadenectomy, systematic D2 dissection was performed less frequently in older patients than in the younger collective in the case of ST and T as well as D3 dissection. Peritonectomy and hyperthermic intraperitoneal chemotherapy were uncommon in elderly patients alongside ST and T compared to younger patients (p < 0.0001). The clinical outcome of major oncological gastric surgery is highly dependent on a patient's age. The elderly show a tremendously increased likelihood of in-hospital mortality and morbidity.

Viktor Ivanovich Bulynin - Professor, Chairman of the Voronezh Regional Society of Surgeons, Honorary Citizen of Voronezh. To the 90th of birthday

Viktor Ivanovich Bulynin - Professor, Chairman of the Voronezh Regional Society of Surgeons, Honorary Citizen of Voronezh. To the 90th of birthday

Nuclear factor erythroid-2-related factor 2 (Nrf2) is a potential prognostic factor in patients with gastric adenocarcinoma

BackgroundGastric cancer is one of the leading causes of cancer-related death, and many researchers are focused on the discovery and use of different biomarkers in prognosis prediction. The use of Nrf2 as a prognostic marker in patients with gastric cancer remains controversial. In this study, we evaluated the expression of Nrf2 protein in gastric adenocarcinoma. Patients and methodsA total of 86 patients who underwent gastric resection and D2 lymph node dissection due to gastric adenocarcinoma were included. Clinicopathological characteristics, such as age, gender, gastrectomy type, pathologic T (pT) and N (pN) stages, tumor grade, tumor type per Lauren’s classification, presence of lymphovascular invasion, and Nrf2 expression were evaluated. ResultsWhile pT, pN, and Nrf-2 expression were found to be negative prognostic predictors for overall survival in one-way analysis of variance, Nrf-2 expression was the only significant negative prognostic predictor in multivariance analysis. pT, pN, diffuse type, high tumor grade, and Nrf-2 expression significantly affected overall survival in Kaplan-Meier survival analyses (p = 0.02, p = 0.03, p < 0.01, p = 0.027, and p = 0.001, respectively). ConclusionsOur findings support that Nrf2 is a prognostic marker in patients with gastric adenocarcinoma. Anti-Nrf2 therapy options should be investigated to improve prognosis in gastric cancer patients.

Multiple complications of postbulbar parapapillary ulcer combined with arteriomesenteric compression of the duodenum

The article explores a clinical observation of a giant postbulbar parapapillary duodenal ulcer with multiple combined complications in the form of penetration into the pancreas, acute gastroduodenal bleeding and subcompensated stenosis occurred against the background of arterio-mesenteric compression of the duodenum in the subcompensation stage. The long course of the disease contributed to the development of alimentary dystrophy, cachexia and severe anemia. After stopping the bleeding, carrying out adequate preoperative preparation, the patient underwent Roux-en-Y gastric resection to “turn off” the ulcer with demucosation of the antrum and formation of the epipyloric stump of the duodenum according to the method modified in the clinic. The postoperative period was complicated by the development of a fistulous variant of duodenal stump suture failure, which was conservatively eliminated. The patient recovered.

Closure of a gastric endoscopic resection defect with a novel closure device.

Closure of mucosal defects after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) has been shown to reduce the risk of delayed bleeding and perforation [1] [2] [3] [4]. Defect closure can be achieved using over-the-scope (OTS) clips, through-the-scope (TTS) clips, or endoscopic suturing [4].

PROGRESSIVE FAILURE AFTER GASTRIC AND DUDEON RESECTION

The scientific literature reviews on the origin of anemia and the development of anemia after gastric and duodenal resection, the state of advanced hyperchromic anemia, both experimental and clinical observations on the possibility of developing forms of anemia are given in this article.

Feasibility of endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge needle.

This study aimed to evaluate the feasibility of performing endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge fine-needle aspiration needle. This was a single-center retrospective study. Fourteen patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with a 22-gauge fine-needle aspiration needle were examined. Fourteen eligible patients were included in this study. The age of patients ranged from 55 to 93 years, with a median of 76 years. Of patients with existing underlying diseases, there were 8 cases of pancreatic cancer (57.1%), 2 cases of metastatic liver tumor (14.3%), 2 cases of bile duct stones (14.3%), 1 case of hilar cholangiocarcinoma (7.1%), and 1 case of gallbladder cancer (7.1%). Regarding gastrointestinal anatomy, there were 11 cases (78.6%) of normal and 3 cases (21.4%) of gastric resection with Roux-en-Y. Reasons for endoscopic ultrasound-guided hepaticogastrostomy were duodenal obstruction in 7 cases (50.0%), surgically altered anatomy in 3 cases (21.4%), and 4 cases (28.6%) of failed endoscopic retrograde cholangiopancreatography. Technical success was achieved in 11 cases (78.6%). Subsequently, 11 cases of technical success were analyzed. There were 5 cases of puncturing B2 (45.5%). The puncture bile duct diameter ranged from 3.1 to 5.7 mm, with a median of 4.4 mm. endoscopic ultrasound-guided antegrade procedures was combined with endoscopic ultrasound-guided hepaticogastrostomy in 2 cases (18.2%). Clinical success was achieved in all the cases. The procedure time ranged from 15 to 93 minutes, with a median duration of 35 minutes. Regarding the type of stent placed in hepaticogastrostomy, a plastic stent was placed in 10 cases (90.9%) and a metal stent was placed in 1 case (9.1%). Early adverse events occurred in 4 cases (36.4%), and all of these cases developed biliary peritonitis, late adverse events occurred in 1 case (9.1%), this was biloma. A change to a 0.025-inch guidewire during the procedure was required in 8 cases (72.7%). Esophageal puncture was not performed. endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge fine-needle aspiration needle is effective. However, in 72.7% of the cases started using the 0.018-inch guidewire, the guidewire was exchanged for a 0.025-inch guidewire during procedure.

LBODP036 A Case of Euglycemic Diabetic Ketoacidosis After Distal Pancreatectomy

Abstract The patient is a 68-year-old female with a past medical history of type 2 diabetes mellitus, pancreatic mass, hypertension, hyperlipidemia, and coronary artery disease who presented to the hospital for elective surgical resection of her pancreatic mass. She underwent robotic-assisted laparoscopic distal pancreatectomy, splenectomy, and gastric wedge resection. Her hospital course was complicated by post-operative bleeding with hemoperitoneum the day after her initial surgery. She returned to the operative room for exploratory laparotomy during which the source of bleeding was identified and repaired. She was transferred to the intensive-care unit for post-operative monitoring. On the fourth day of admission, the patient became markedly acidotic. Her labs revealed a bicarbonate level of 12 mmol/L and a pH of 7.24. Her anion gap was elevated to 17. Endocrinology was consulted for suspected euglycemic diabetic ketoacidosis. Beta-hydroxybutyrate was elevated to 5.10 mmol/L (0 - 0.29 mmol/L). The patient's blood glucose was 159 mg/dL. Of note, the patient does take Empagliflozin at home. This medication has been associated with euglycemic diabetic ketoacidosis; however, she had not received this medication for five days prior to the onset of diabetic ketoacidosis. Glucosuria is expected to return to baseline after discontinuation of Empagliflozin within approximately three days. A urinalysis was checked at the time of consultation, and the patient did have a large amount of glucose in her urine which suggests that Empagliflozin was still acting to produce glucosuria. The patient was treated with intravenous insulin and fluids per the institution's protocol for the management of diabetic ketoacidosis. Her acidosis rapidly improved, and she was transitioned to subcutaneous insulin to manage her diabetes prior to discharge. This is an interesting case of euglycemic diabetic ketoacidosis due to the multifactorial precipitants: the dwindling effect of Empagliflozin five days after discontinuation, the loss pancreatic beta cell mass after distal pancreatectomy, and the stress of multiple surgeries complicated by life-threatening post-operative bleeding. Presentation: No date and time listed

Impact of perioperative chemotherapy in the treatment of patients with gastric cancer.

Perioperative chemotherapy (PeriCh) is the current standard of care for stage II/III gastric cancer tumors in Europe. However, when it concerns patients who endure complications during PeriCh it is unclear if it increases the risk of postoperative complications and other poorer surgical outcomes. We aim to demonstrate if there is an association between having complications during PeriCh and postoperative complications and histopathological response. We conducted a retrospective, transversal, and observational study, including all patients with diagnosed gastric cancer who underwent PeriCh followed by surgical resection during the period of eight years. We included 80 patients with a median age of 64.0years (min 24, max 78). Eighty-eight-point eight percent ended the chemotherapy regime proposed, with a median duration of 42 days, and were also submitted to gastric resection: 58.8% total gastrectomy and 41.2% distal gastrectomy. Twelve-point five percent of the patients had no complications during the PeriCh period and 16.3% had >2 complications. Twenty-five percent of patients had a histological response of <10% of tumor burden, but in 41.3% only regression of <50% could be obtained. No significant association was found between complications during PeriCh and adverse surgical outcomes (P = .497). Patients with complications during PeriCh had slightly higher median time difference from end of PeriCh until surgery, but with no statistical significance (P = .575). In our sample, the existence of association between complications during PeriCh and postoperative complications or histological response was not demonstrated.

The Impact and Clinical Implications of Gastric Surgery on the Gastric Conduction System

Chronic symptoms of gastric dysfunction are common following gastric surgery, but the mechanisms underlying these have remained poorly understood. Disturbances of foregut motility are suspected to play a central role, however knowledge of how these abnormalities manifest and relate to symptoms requires elucidation. Emerging data suggests that abnormalities of the gastric conduction system are a common consequence of gastric surgery and may contribute to dysmotility and post-operative symptoms. This review provides a primer on the gastric conduction system. The normal physiology of the gastric conduction system and factors that influence resilience to surgery are outlined, together with focused discussion on three surgical procedures that impact post-operative gastric dysfunction: resection of the gastric pacemaker, resection or bypass of the pylorus, and vagotomy. The mechanistic pathways that underpin the clinical effects of these procedures are discussed. Future horizons are also evaluated, including newly established body surface gastric mapping techniques that provide a non-invasive method to detect changes in the gastric conduction system and relate these to symptoms in postoperative patients, with the goal of developing targeted interventions for prevention and therapy.

The Cancer Hub Approach for Upper Gastrointestinal Surgery During COVID-19 Pandemic: Outcomes from a UK Cancer Centre

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic caused unprecedented disruption to global healthcare delivery. In England, the majority of elective surgery was postponed or cancelled to increase intensive care capacity. Our unit instituted the ‘RM Partners Cancer Hub’ at the Royal Marsden Hospital in London, to deliver ongoing cancer surgery in a ‘COVID-lite’ setting. This article describes the operational set-up and outcomes for upper gastrointestinal (UGI) cancer resections performed during this period.MethodsFrom April 2020 to April 2021, the Royal Marsden Hospital formed the RM Partners Cancer Hub. This approach was designed to coordinate resources and provide as much oncological treatment as feasible for patients across the RM Partners West London Cancer Alliance. A UGI surgical case prioritisation strategy, along with strict infection control pathways and pre-operative screening protocols, was adopted.ResultsA total of 231 patients underwent surgery for confirmed or suspected UGI cancer during the RM Partners Cancer Hub, with 213 completed resections and combined 90-day mortality rate of 3.5%. Good short-term survival outcomes were demonstrated with 2-year disease free survival (DFS) and overall survival (OS) for oesophageal (70.8% and 72.9%), gastric (66.7% and 83.3%) and pancreatic cancer resections (68.0% and 88.0%). One patient who developed perioperative COVID-19 during the RM Partners Cancer Hub operation made a full recovery with no lasting clinical sequelae.ConclusionOur experience demonstrates that the RM Partners Cancer Hub approach is a safe strategy for continuing upper gastrointestinal (GI) resectional surgery during future periods of healthcare service disruption

Radiomics signature for predicting postoperative disease-free survival of patients with gastric cancer: development and validation of a predictive nomogram.

PURPOSE Radiomics can be used to determine the prognosis of gastric cancer (GC). The objective of this study was to predict the disease-free survival (DFS) after GC surgery based on computed tomography-enhanced images combined with clinical features. METHODS Clinical, imaging, and pathological data of patients who underwent gastric adenocarcinoma resection from June 2015 to May 2019 were retrospectively analyzed. The primary outcome was DFS. Radiomics features were selected using Least Absolute Shrinkage and Selection Operator algorithm and converted into the Rad-score. A nomogram was constructed based on the Radscore and other clinical factors. The Rad-score and nomogram were validated in the training and validation groups. RESULTS Totally, 179 patients were randomly divided into the training (n=124) and validation (n=55) groups. In the training group, validation group, and overall population, the Rad-score could be divided into categories indicating low, moderate, and high risk of recurrence, metastasis, or death; all risk categories showed a significant difference between the training, validation, and overall population groups (all P < .001). Positive lymph nodes (hazard ratio (HR)=3.07, 95% CI: 1.52-6.23, P=.002), cancer antigen-125 (HR=3.24, 95% CI: 1.54-6.80, P=.002), and the Radscore (HR=0.73, 95% CI: 0.61-0.87, P < .001) were independently associated with DFS. These 3 variables were used to construct a nomogram. In the training group, the areas under the curve at 3 years were 0.758 and 0.776 for the Rad-score and the nomogram, respectively, while they were both 1.000 in the validation group. The net benefit rate was analyzed using a decision curve in the training and validation groups, and the nomogram was superior to the single Rad-score. CONCLUSION Rad-score is an independent factor for DFS after gastrectomy for GC. The nomogram established in this study could be an effective tool for the clinical prediction of DFS after gastrectomy.

The vegetative disbalance and its effect on the formation of peptic ulcer of gastroenteroanastomosis

Research objective. To study the effect of vegetative nervous system dysfunction on mechanisms of peptic ulcer of gastroenteroanastomosis formation and to improve the results of treatment of patients after gastric resection for peptic ulcer disease.Material and methods. The study included 30 patients with peptic ulcers of gastroenteroanastomosis being operated on for gastric ulcer and duodenal ulcer. Instrumental research included: cardiorhythmography, esophagogastroduodenoscopy, intragastric pH-metry, electrogastrography, laser Doppler fl owmetry.Results. In patients with peptic ulcers of gastroenteroanastomosis, according cardiorhythmography, parasympathicotonia prevailed in 20 (66,7%) patients, sympathicotonia was observed in 8 (26,7%) patients, eutonia — in 2 (6,6%) patients. Microcirculation data against the background of sympathicotonia were signifi cantly lower than in the control group (p&lt;0,05) and lower than those in parasympathicotonia and eutonia. With the hyperkinetic type of motility, the predominance of parasympathicotonia(87,5% patients), while the acid-producing function of the stomach was increased in 70% patients (рН 0,9±0,3). Autonomic dysfunction and helicobacteriosis were observed in 26 patients (86,6%). Correlation analysis between cardiorhythmography data and gastric acidity established positive correlation of average strength (r=0,726), which determined the important role of acid-peptic exposure against the background of an increase in the tone of the parasympatic part of the vegetative nervous system. With the predominance of parasympathicotonia, M-anticholinergic Нyoscine butylbromide was included in the complex therapy. After the treatment, the results of cardiorhythmography showed the normotensive nature of the cardiorhythmograms, motor data improved in 60% patients, the acidity data corresponded to the normality (рН 1,2–2,0).Conclusions. The results of the study showed the predominance of parasympathicotonia in patients with peptic ulcers of gastroenteroanastomosis, which contributes to impaired microcirculation, motor- evacuation and secretory functions of the gastric stump and creates conditions for persistence. The сardiorhythmography made it possible to objective assess of the state of the vegetative nervous system. The inclusion of hyoscinebutylbromide in complex treatment with the predominance of parasympathicotonia has a modulating effect on the vegetative nervous system.

Surgical considerations and outcomes of minimally invasive approaches for gastric cancer resection.

Despite high mortality rates from gastric cancer, surgical management remains critical for curative potential. Optimal outcomes of gastric cancer resection depend on a multitude of variables, including the extent of resection, scope of lymphadenectomy, method of reconstruction, and potential for a minimally invasive approach. Laparoscopic gastrectomy, compared with open gastrectomy, has been analyzed in numerous randomized control trials. Generally, those trials demonstrated statistically similar postoperative complication rates, mortality, and oncologic outcomes between the two approaches. Although laparoscopic gastrectomy requires longer operative times, significant improvements in estimated blood loss, postoperative length of stay, and return of bowel function have been noted in patients who undergo laparoscopic gastrectomy. These short-term benefits, along with equivalent oncologic results, have influenced national guidelines in both Eastern and Western countries to recommend laparoscopy, especially for early stage disease. Although robotic gastrectomy has not been as widely validated in effective trials, studies have reported equivalent oncologic outcomes and similar or improved postoperative complication and recovery rates after robotic gastrectomy compared with open gastrectomy. Comparing the two minimally invasive gastrectomy approaches, robotic surgery was associated with improved estimated blood loss, incidence of pancreatic sequela, and lymph node harvests in some studies, whereas laparoscopy resulted in lower operative times and hospital costs. Ultimately, when applying outcomes from the literature to clinical patient care decisions, it is imperative to recognize these studies' range of inclusion criteria, delineating between patients originating from Eastern or Western countries, the use of neoadjuvant chemotherapy, the volume of surgeon experience, and the extent of gastrectomy, among others.

S1605 Comparable Outcomes of Endoscopic, Surgical, and Hybrid Resection of Gastric GIST

Introduction: Gastrointestinal stromal tumors (GIST) are rare, comprising < 1% of all gastrointestinal tumors, and most commonly arise in the stomach (60%). Surgical resection (SR) has been the mainstay of therapy, however endoscopic resection (ER) is being performed for small lesions, while hybrid resection (HR) can be used for bigger lesions, both becoming a viable alternative to surgery. We aimed to analyze Gastric GIST (G-GIST) management trends, compare outcomes, and hospital resource utilization between ER, SR, and HR techniques in the USA. Methods: Using ICD-10 diagnosis code for G-GIST (C49.A2), we extracted adult ( >20y) patients’ data from Nationwide Inpatient Sample (2017-2019yy). We used the procedure codes for ER (0D568ZZ, 0DB68ZZ, 0DT78ZZ), open and laparoscopic SR(0D564ZZ, 0DB64ZZ, 0DB60ZZ, 0DT74ZZ,0DT70ZZ), and HR (endoscopic and laparoscopic codes combined), and defined technical procedural and systemic complications. Mortality, complications, length of stay (LOS), and hospitalization charges were used as outcomes. Statistical analysis was performed with SAS. Results: A total of 145 ER, 7875 SR, and 70 HR procedures for G-GIST management was identified. According to different approaches, there was no difference in primary payer types or median household income. There was slight male to female predominance in ER and HR but not in the SR group. Racial disparities were noted in the ER >SR but not in HR (Figure). Most procedures were performed in teaching institutions: ER (93%), SR (86%), and HR (86%). Mortality for SR was 0.8%, and no inpatient deaths were recorded for ER or HR. Mean charges were highest for HR ($163,794) and lowest for ER ($86,811), with LOS highest for HR (10.7d), followed by ER (∼7d) and SR (5.5d). More complications were noted in HR (43%, vs 28% in ER and 18% in SR) (Table). Most SR and HR patients were discharged home (94% and 93%, respectively); A lesser percentage of ER (72%) were discharged home with a relatively higher percentage of 28% sent to long-term care facilities compared to SR (5%) and HR (7%). Conclusion: Minimally invasive management of G-GIST is evolving, with surgery still being most common. Both endoscopic and hybrid techniques are promising alternatives to surgery and show a lower mortality rate, however, with a higher percentage of non-fatal complications (both), increased cost (HR only), and increased LOS (both) compared to SR. Larger studies can help guide providers in choosing the optimal individual approach in G-GIST management.Figure 1.: Sociodemographic Analysis of Endoscopic, Surgical and Hybrid Gastric GIST Resection Table 1. - Hospital Resource Utilization and Complications for Endoscopic, Surgical and Hybrid Gastric GIST Resection Endoscopic Resection 95% CI Surgical Resection 95% CI Hybrid Resection 95% CI Mean Charges $86,811 $54,981-$118,641 $93,112 $87,943-$98,280 $163,794 $114,128-$213,461 Mean Length of Stay (days) 6.9 4.6-9.2 5.5 5.2-5.8 10.7 7.1-14.4 Complications 27.6% 11.2-44% 17.8% 15.9-19.7% 42.9% 16.8-68.9%

S1843 The Path of Least Resistance: A Case of the Lemmel

Introduction: Lemmel Syndrome is defined as obstructive jaundice caused by a periampullary duodenal diverticulum (PAD) compressing the intrapancreatic common bile duct (CBD) with resultant bile duct dilatation and obstruction. Management is based on symptomatology, ranging from conservative management to endoscopic extraction of retained food debris, or surgery. We present a unique case of Lemmel Syndrome in a patient who suffered from recurrent obstructive jaundice and underwent multiple endoscopic and ultimately, surgical interventions Case Description/Methods: A 56-year-old obese female with a history of alcohol use disorder initially presented with right upper quadrant abdominal pain for 2 days. Physical exam was remarkable for right upper quadrant tenderness. Labs revealed total bilirubin 3 mg/dL. Complete blood count was within normal limits. Viral hepatitis panel and CA 19-9 were unremarkable. Ultrasound gallbladder showed cholelithiasis without cholecystitis with mild CBD dilatation. MRCP revealed a large 6 cm multiloculated mass centered near the pancreatic head/ampulla of Vater, with internal heterogeneity and multiple air-fluid levels and internally contiguous with duodenal lumen. She was given broad spectrum antibiotics and an upper endoscopy with endoscopic ultrasound was performed revealing a large, non-bleeding periampullary diverticulum impacted with food debris. The food debris was extracted. Multiple such procedures were needed in a short period of time. She continued to suffer from recurrent obstructive jaundice for several months, requiring a cholecystectomy, Roux-En Y hepaticojejunostomy, and gastric antrum resection with Roux-En Y BillRoth II gastrojejunostomy in an attempt to divert food debris away from the diverticulum. She has now developed stenosis at the hepaticojejunostomy requiring ERCP with dilation of the anastomosis, and stenting, as well as percutaneous transhepatic cholangiography, internal external biliary drain placement, lithotripsy of hepatic duct stones, and covered metal stent placement. (Figure) Discussion: Treatment of Lemmel Syndrome incorporates a variety of modalities. A conservative approach is usually preferred, but invasive intervention may sometimes be required. The most definitive approach would be a Whipple procedure. However, in an obese patient, this would be associated with significant morbidity and mortality risk. Our case portrays an unusual approach which offered the patient a less invasive combined endoscopic, interventional radiology and surgical treatmentFigure 1.: A: Initial MRI which shows duodenal diverticulum with biliary dilation consistent with Lemmel Syndrome B: Initial Cholangiogram: Stent within left hepatic duct as well as central right hepatic duct appearing goblet shaped with stones (as shown with arrows) C: Subsequent imaging reveals right hepatic duct status post stone extraction, appearing relatively normal (compare with Image B).

Surgical treatment of acute complicated duodenal ulcer

The aim. To analyze treatment approaches and tactics and improve acutely complicated duodenal ulcers (DU) treatment results.&#x0D; Materials and methods. The results of the analysis of the surgical treatment of acutely complicated duodenal ulcers (a combination of 3 and/or 4 combined complications) are presented for 2 periods: the 1st (2000–2014) years (group A) – 47 patients, the 2nd (2015–2021) years (group B) – 34 patients.&#x0D; Results. 81 (100 %) patients were operated on for acutely complicated duodenal ulcers, of which 68 (84.3 %) patients had a combination of three complications, and 13 (15.7 %) had four complications. Out of 81 patients, 72 had bleeding complications, which is 89.3 %. Complications of ulcer perforation – in 36 patients, 44.7 % of all other complications.&#x0D; Based on the obtained analysis data, there is a steady trend towards an increase in the share of organ-sparing operations (OSO) by 1.6 times (from 50.9 % to 81.4 %), a decrease in the number of gastric resections (GR) by 2.9 times (from 14.9 % to 4.9 %) and palliative operations (PO) by 3.2 times (from 15.8 % to 4.9 %) with a relatively stable number of performed organ-preserving operations (OPO): in group A – 17 (24 .6 %) interventions, in group B – 4 (21.1 %).&#x0D; Conclusions. The use of modern measures of endoscopic hemostasis made it possible to adequately prepare and operate on patients in the delayed period, and their share from the first period to the second increased by 2.9 times.&#x0D; The number of patients who underwent emergency surgery with ulcer perforation and bleeding as combined complications decreased in the second period compared to the first by 2.5 times, which is associated with the widespread use of modern proton pump inhibitors (PPIs) in the conservative treatment of DU.&#x0D; The number of complications and mortality of this cohort of patients also significantly decreased due to the use of endoscopic hemostasis methods, making it possible to stabilize and prepare patients on the operating table.&#x0D; According to the analysis results, it became known that the chosen active-individualized tactics and the use of developed algorithms for choosing the type of surgical intervention made it possible to achieve a stable level of postoperative mortality at 8.1 %.

222. ARE GASTRIC MAPPING BIOPSIES NECESSARY TO DETERMINE THE DISTAL RESECTION MARGIN FOR SIGNET RING ADENOCARCINOMAS OF THE OESOPHAGO-GASTRIC JUNCTION?

Abstract In our department patients with oesophago-gastric junctional adenocarcinomas with signet ring differentiation undergo a second endoscopy for gastric mapping biopsies to investigate the extent of tumour extension into the proximal stomach. This is due to the perceived aggressive morphology and to avoid a R1 (microscopic positive) resection at the distal margin. Our aim was to elucidate whether gastric mapping endoscopic biopsies are necessary prior to resection in signet ring adenocarcinomas of the oesophago-gastric junction (OGJ). Patients with operable OGJ adenocarcinomas with signet ring morphology were retrospectively analysed from 2011–2021 from our databank of completed oesophagectomies at our upper gastrointestinal cancer surgical department. From 2014–2021, OGJ adenocarcinomas identified with signet ring differentiation were subjected to a second invasive endoscopy with gastric mapping biopsies to determine the distal ex-tent of microscopic invasion into the cardia and beyond. These were analysed to determine the histopathological yield from gastric mapping biopsies and the number of cases with a positive (R1) distal resection margin. From 2014, 322 oesophagectomy cases were completed and these were analysed further. Of these, 21.7% (n = 70) were found pre-operatively to have signet ring differentiation and thus underwent a second gastric mapping endoscopy. Within the signet ring morphology cohort, only one patient (1.4%) was found to involve a R1 resection margin which necessitated a second operation involving gastric resection and colonic interposition. Our results suggest that patients with signet ring adenocarcinoma of the OGJ do not need gastric mapping biopsies to determine the distal margin prior to resection. Although considered a more aggressive subtype of adenocarcinoma, radial infiltration from the tumour does not seem to affect conventional surgical oncological margins.

About the first gastric surgeries performed in Saint Petersburg in the ХIХ century

The article is devoted to the history of gastric surgery in Saint Petersburg (Russia) in the XIX century. In the last decades of the 19th century, there was a breakthrough in surgery - surgeons from all over the world began to operate on the stomach. For the first time in Saint Petersburg and in Russia, Russian surgeons M.K. Kitaevsky, D.M. Monastyrsky and N.V. Ekk performed stomach resection for cancer by Billroth I method (M.K. Kitaevsky, 16.07.1881) and gastroenteroanastomosis for cicatrical pyloric stenosis (N.D. Monastyrsky, 13.03.1882), and at the meeting of the Society of Russian Doctors in Saint Petersburg in May 1882, V. Ekk proposed to overlap an anastomosis between the stump of the resected stomach and the loop of the small intestine that was realized by the Viennese surgeon T. Billroth only 3 years later in 1885, and got the name of the modification of gastric resection by the Billrot II method. It should be noted that M.K. Kitaevsky and N.D. Monastyrsky worked at Petropavlovsky Hospital - on the basis of which the Women's Medical Institute was established in 1897 (now the Pavlov First Saint Petersburg State Medical University).