Gastric Tube Research Articles

Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis.

One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.

Esophageal perforation in premature newborns

BACKGROUND: Esophageal perforation is a rare entity in newborns. This condition is most common in premature babies with very low and extremely low birth weight. The major cause of such pathology is considered to be iatrogenic trauma of either pharynx or esophagus, their soft tissues being delicate and tender enough to produce delamination and perforation of their wall. As a rule, this occurs as a complication of either a difficult tracheal intubation soon after birth or during some troubles with oro- or nasogastric tube insertion. AIM: To analyze our experience of revealing and treatment of esophageal perforation in preterm babies, and to demonstrate conservative approach as a possible as well as reasonable option in such cases. METHODS: A retrospective study of neonatal esophageal perforation cases was performed, including newborns without any congenital esophageal malformations or previous surgical procedures. During 2017–2022 9 newborns with esophageal perforation were treated at neonatal intensive care unit and neonatal departments of Childrens’ City Multidisciplinary Clinical Specialized Center of High Medical Technologies of Saint Petersburg. All of them were premature, 2 having very low, and 7 having extremely low birth weight. The incidence of that condition appeared to be 1:1320 live births. RESULTS: 8 patients were treated conservatively. This included adjustment of artificial lung ventilation, pain control, antibiotics, cancellation of gastric enteral feeding and administration of total parenteral nutrition. Babies with hydrothorax, pneumothorax or ascites underwent thoraco- or laparocentesis. 2 patients died, both being born at 23th week of gestation. In both cases death occurred from polyorganic insufficiency. The mortality rate appeared to be 22%. CONCLUSION: In most cases the esophageal perforation in premature babies can be treated conservatively, the efficacy of such treatment being largely dependent on early diagnosis of this complication. An important key-point in it is a radiologic control of gastric tube location.

Gastro-tracheal fistula following esophageal cancer surgery through the retrosternal route: a case report

BackgroundGastro-tracheal fistula is a rare but serious complication after esophageal surgery, often requiring long-term treatment and invasive procedures. Gastro-tracheal fistula usually occurs through the posterior mediastinal route and rarely through the retrosternal route. No previous reports have described gastro-tracheal fistula after retrosternal route reconstruction was cured by conservative treatment.Case presentationA 70-year-old man with lower thoracic esophageal cancer underwent thoracoscopic esophagectomy in the prone position and gastric tube reconstruction through the retrosternal route with neck anastomosis after neoadjuvant chemotherapy. Despite anastomotic leakage on postoperative day 10, his general condition was stable, and he was managed conservatively with antibiotics and gastric tube decompression. On day 29, he presented with high fever and a gastro-tracheal fistula was observed by esophagography. Conservative management was continued because the patient remained stable. On day 48, esophagography showed that the fistula was undetectable. The patient was able to take fluids orally. He progressed well on an oral diet and was transferred to a different hospital.ConclusionsA gastro-tracheal fistula, although rare, can occur after retrosternal route reconstruction. When a patient is stable, gastro-tracheal fistula after retrosternal route reconstruction may be cured by conservative treatment.

국내 간호대학생의 핵심간호술 교육 중재의 효과: 체계적 고찰

Objectives This study systematically reviewed the effectiveness of core nursing skill training intervention programs for nursing students in Korea. Methods Literature searches were conducted using the databases RISS, KISS, DBpia, and KCI for papers published up to June 2024, with the keyword ‘core nursing skills’. A total of 130 papers were identified, and ultimately, 14 papers were selected for the literature review. Results The literature review revealed that among the research designs, 1 was randomized and 13 were nonrandomized. Core nursing skill training interventions included studies using various methods of retraining and evaluation (10 papers) and studies using various methods of self-practice and evaluation (4 papers). Retraining and evaluation methods included traditional retraining, STEPS Model retraining, senior mentoring retraining, multimedia retraining, and online learning retraining, while self-practice and evaluation methods included traditional self-practice, scenario-based self-practice, Virtual Reality-based self-practice, and self-observation methods. The most frequently applied core nursing skill was subcutaneous injection, appearing in 10 studies, followed by vital signs measurement, intramuscular injection, intermittent gastric tube feeding, and foley catheterization, each appearing in 8 studies. Outcome variables of core nursing skill training programs showed significant effects on confidence in performance (9 papers), clinical performance ability (4 papers), self-efficacy (3 papers), and knowledge (3 papers). Conclusions Korean nursing colleges have researched various intervention programs to achieve core nursing skill competency levels in accordance with the Nursing Education Evaluation Criteria. These programs have shown significant effects on performance confidence, clinical performance ability, and self-efficacy. Therefore, there is a need to develop and utilize diverse intervention programs to enhance learning motivation and satisfaction among nursing students.

A Meta-Analysis of the Effect of Modified Gastric Tube Length on Enteral Nutrition in Stroke Patients

Objective: To systematically evaluate the effect of modified length of gastric tube implantation in stroke patients. Methods: Randomized controlled studies on the effect of narrative therapy on negative emotions of malignant tumor patients were published in PubMed, EMbase, Web of Science, Cochrane Library, CNKY. Wanfang Data, VIP Database and CBM disc from database establishment to May 2021. RewMan 5.2 software was used for the meta-analysis. Results: Ten articles were included, involving 1140 patients in total. Results of meta-analysis showed that improved length of gastric tube implantation could reduce the incidence of aspiration pneumonia in stroke patients with enteral nutrition [OR = 0.18, 95% CI (0.10, 0.31), P &lt; 0.00001], reduce gastroesophageal reflux rate (OR = 0.13, 95% CI (0.04, 0.38), P &lt; 0.0002], the incidence of aspiration (OR = 0.23, 95% CI (0.11, 0.38), P &lt; 0.00001], the incidence of abdominal distension and diarrhea (OR = 0.13, 95% CI (0.06, 0.28), P &lt; 0.00001], the incidence of choking cough (OR = 0.20, 95% CI (0.07, 0.61), P &lt; 0.005], but no difference between the two groups in terms of reducing gastric residual (OR = 0.10, 95% CI (2.40, 2.60), P = 0.94]. Conclusions: The modified length of the gastric tube can replace the traditional length of the gastric tube in the application of stroke patients, can reduce the complications of enteral nutrition, is safe and feasible. However, due to the limitation of the quality and quantity of the included studies, we should be cautious about the results of this meta-analysis and expect to carry out more large-sample and high-quality randomized controlled trials for demonstration.

Application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy

Objective: To explore the application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy. Methods: Overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance is suitable for patients with advanced gastric cancer (clinical stage: cT1b~4aN0~3M0) and esophageal invasion <3 cm, who underwent radical total gastrectomy+ overlap esophagojejunostomy. The main operation procedure was performed as follows: A titanium clip was used for fixation of the full anterior wall of esophagus before overlap esophagojejunostomy, and the side-to-side esophagojejunostomy was performed with the linear stapler under the guidance of gastric tube. Then the titanium clip was removed after confirming that the correct cavity was entered. Finally, the common outlet was closed by two barbed sutures. A descriptive case series study was conducted. The clinical data of patients who underwent laparoscopic radical gastrectomy and overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance in Guangdong Provincial Hospital of Chinese medicine and the First Affiliated Hospital of Guangzhou University of Chinese medicine from May 2021 to June 2023 were retrospectively analyzed. Results: A total of 42 patients were collected, and all of them were successfully completed laparoscopic total radical gastrectomy without conversion to laparotomy or perioperative death. The esophagojejunostomy time, operative time, intraoperative blood loss was 17(5-25) minutes, (258.8±38.0) minutes and 50(20-200) ml, respectively. The incidence of esophageal false lumen was 0%, and there were no intraoperative complications. The time of gastric tube removal, initial fluid diet intake and the duration of postoperative hospital were 2(1-5) , 4(1-8) and 8(4-21) days, respectively. There were no postoperative anastomotic hemorrhage, anastomotic stenosis and other related complications. One patient (2.38%) developed a Clavien-Dindo IIIb complication, which was abdominal hemorrhage after operation. The second surgical exploration confirmed that the patient was bleeding due to gastroduodenal artery rupture. After intraoperative suture hemostasis, fluid expansion, blood transfusion and other treatments, the patient was discharged on the 15th day after the operation. Three patients (7.14%) developed Clavien-Dindo grade II complications, including anastomotic leakage, chylous leakage and pulmonary infection, and were discharged after conservative treatment such as anti-infection and prolonged retention of drainage tube. Conclusions: Laparoscopic overlap method for intracorporeal esophagojejunostomy with anterior esophageal wall fixation and gastric tube guidance can shorten the time of esophagojejunostomy and prevent the occurrence of false lumen, and do not increase anastomose-related complications.

Pull-through endoscopic vacuum-assisted closure therapy for complicated leaks of the gastrointestinal tract – a novel technique

Background and study aims Endoscopic vacuum-assisted closure (EVAC) of post-surgical leaks is an increasingly applied technique. Precise intracavitary sponge placement is technically challenging. Here, we describe a novel EVAC therapy using a combined external and endoluminal, pull-through technique. Patients and methods In this retrospective cohort study, we included all patients treated with pull-through EVAC for post-surgery leaks. During endoscopy, the proximal tip of the percutaneous drainage was visualized within the extraluminal abscess cavity, grasped with forceps, and pulled out orally while maintaining the distal end of the drainage above skin level. A foam sponge was fixed to the tip of the percutaneous drainage and sutured to a gastric tube at the other end. The sponge was placed in the cavity by pulling at the percutaneous drainage. Finally, the gastric probe was channeled nasally and suction was applied. Re-interventions comprised pulling the gastric tube, exchanging the sponge, and re-positioning, as described above. Therapy was stopped after closure or complete epithelialization of the leakage. Results Overall, 7 patients were included between 2021 and 2023. Median duration of pull-through EVAC therapy was 30 days (IQR 11 – 37 days) and median number of endoscopic interventions was 6 (IQR 4 – 10). Technical and clinical success was achieved in all (100%) and in 6 of 7 patients (85.7%), respectively. In total, one major bleeding complication associated with EVAC therapy occurred (14.3%). Conclusion Pull-through EVAC therapy is safe and effective in patients with large and challenging post-surgical leaks of the upper GI tract.

Evaluation of esophagogastric anastomosis with additional mechanical anti-reflux barrier after proximal gastrectomy

The application of proximal gastrectomy for suitable upper gastric cancer and AEG patients is increasing along with the promotion of the concept and technology for function-preserving partial gastrectomy. The following problems such as postoperative reflux esophagitis and anastomotic stenosis naturally become the focus of academic field. Based on the understanding of the anti-reflux structure and function of the esophagogastric junction, scholars have successfully established some representative esophagogastric anastomosis methods with additional mechanical anti-reflux barrier, including gastric tube reconstruction, side overlap esophagogastrostomy, and double flap technique. Subsequently, a series of improved esophagogastric reconstruction methods have been derived. At present, the recognized ideal reconstruction method has not yet been established, and there are also misunderstandings in related concepts and cognition. Based on the literatures and the authors' own practical experience, this paper draws on the research results in the field of surgical treatment for reflux esophagitis, and discusses the theoretical basis, key details and anti-reflux effect of the above-mentioned digestive tract reconstruction methods after proximal gastrectomy, as well as the possible problems in the exploration of innovative surgical methods at home and abroad.

A long-term follow-up study of gastric peroral endoscopic myotomy (G-POEM) in a large cohort of patients with postsurgical gastroparesis.

Postoperative gastroparesis occurs after surgeries which affect the upper digestive tract. Gastric peroral endoscopic myotomy (G-POEM) is a treatment for postoperative gastroparesis. The present study boasts the long-term efficacy and safety of G-POEM in a large cohort of patients. Gastroparesis Cardinal Symptom Index (GCSI) and Gastroesophageal Reflux Disease Questionnaire (GERDQ) were utilized for the assessment of postsurgical gastroparesis symptoms. Gastroscope was used to observe the anastomotic site. Three-dimensional ultrasound was used to measure the morphological structure of the gastric antrum and pylorus tube. Gastric emptying time was calculated by analyzing the volume change of gastric antrum. Significant clinical effectiveness of G-POEM was observed. The GCSI score, including each subscale score, showed significant decrease after G-POEM. Before G-POEM, there was a negative correlation between GCSI score and the inner diameter of pylorus, as well as a positive correlation with the length of pyloric tube. The similar results were found in the scores of nausea/vomiting and postprandial fullness/early satiety subscales. No correlation was observed between GCSI score and the emptying time, nor between the emptying time and the parameters of antrum morphology. After G-POEM, no correlation was found between GCSI (including subscales) score, the emptying time, and the parameters of antrum morphology. Patients who exhibited as clinical non-responders often accompanied with GERD symptoms. After G-POEM, the score of GERDQ decreased significantly. Either before or after G-POEM, no correlation was noticed between GERDQ scores, the emptying time and the parameters of antrum morphology. The technique of G-POEM was demonstrated as a minimally invasive approach with the long-term efficacy and safety in therapying postoperative gastroparesis.

The Benefits of Silicone Laryngectomy Tubes at the Time of Laryngectomy-A Case Series Spanning 17 Years.

Although total laryngectomy (TL) is a well-established surgical procedure with clear functional or oncologic indications, the peri- and postoperative care for those undergoing TL is variable, particularly regarding postlaryngectomy tracheostoma management. This study examined TL outcomes from a single institution with the immediate perioperative use of soft silicone laryngectomy tubes. More specifically, we explored potential complications associated with immediate perioperative use of a flexible laryngectomy tube (LaryTube and StomaSoft) and the use of heat and moisture exchange (HME) devices in association with peri- and postoperative care. A case series including all patients undergoing TL by one primary surgeon at a tertiary care hospital between 2006 and 2023 were assessed. Variables of interest included hospital average length of stay (LOS) in hospital, use of laryngectomy tube and an HME, primary tracheoesophageal puncture voice restoration at time of TL, discharge feeding, stoma-related complications, and overall complications. Seventy-two patients were included over the study period, and all utilized a laryngectomy tube and HME in the perioperative period without complications. Fifty-six patients (77.7%) had concurrent neck dissections and nine (15%) underwent total laryngopharyngectomy. Sixty-two patients (86%) underwent TL for squamous cell carcinoma of the larynx or hypopharynx and 35 of these (56%) were salvage surgeries. Mean LOS was 8.4 (3-45) days, and 63 patients (88%) were discharged with nasal gastric tube feeding. Of the six patients (8%) who were readmitted for complications, zero (0%) were related to the laryngectomy tube or to stoma-related complications (e.g., dehiscence, infection, mucous plugging). No patient who utilized a laryngectomy tube and HME device in the perioperative period experienced stomal stenosis. Laryngectomy tubes combined with an HME can be employed safely and successfully in a high percentage of laryngectomy patients placed perioperative. No instances of postlaryngectomy tracheostoma stenosis occurred in association with perioperative laryngectomy tube with HME use. These collective data support the use of a laryngectomy tube with HME in the immediate perioperative period, with low risk of complications.

Risk Reduction of Severe Anastomotic Leakage by Evaluation of Blood Perfusion Using Indocyanine Green After Minimally Invasive Esophagectomy Followed by Narrow Gastric Tube Reconstruction

Risk Reduction of Severe Anastomotic Leakage by Evaluation of Blood Perfusion Using Indocyanine Green After Minimally Invasive Esophagectomy Followed by Narrow Gastric Tube Reconstruction

Laparoscopic and thoracoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation for esophageal cancer: a prospective multicenter case-series outcome

IntroductionTo mitigate gastroparesis as well as other post-operative complications, we undertook a prospective multicenter study to assess the feasibility, safety, and efficacy in the short-term outcomes of laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation.MethodsA prospective descriptive study on 37 patients with laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation from January 2019 to March 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated.ResultsIn our study, all patients were male, with dysphagia as the predominant symptom (45.9%). Esophageal cancer incidence was similar between middle and lower thirds. Nodules were the primary finding on esophagoscopy (48.6%). Preoperative pyloric dilation averaged 31.2 min without complications. Surgical duration ranged from 225 to 400 min (mean 305). Gastric tube fluid volume averaged 148.9 ± 110.66 ml per day. Among 34 post-operative cases underwent gastric transit scans, most had non-dilated stomachs with efficient pyloric drug circulation. Three cases required prolonged ventilation, precluding pyloric circulation scans. Four patients developed chylous fistula, one requiring chest tube embolization. Recurrent laryngeal nerve damage occurred in 10.8% of cases.ConclusionAfter evaluating esophageal cancer patients undergoing laparoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation, it was found that this procedure is safe, effective, and significantly reduces postoperative gastroparesis and related complications.

Peak expiratory flow predicts the occurrence of postoperative pneumonia after esophagectomy for esophageal cancer.

Expiratory flow is an important factor in the achievement of airway clearance that is required to prevent postoperative pneumonia (POP). Although peak expiratory flow (PEF) has been shown to predict the occurrence of POP in lung cancer patients after lobectomy, its predictive power in relation to esophagectomy for esophageal cancer remains unknown. This study assesses PEF as a predictor of POP in patients with esophageal cancer undergoing radical esophagectomy. We conducted a single-center, retrospective cohort study of patients who underwent radical esophagectomy with gastric tube reconstruction at our institution between January 2007 and December 2022. Preoperative pulmonary functions, including PEF, were assessed before surgery. Additionally, POP was diagnosed as a Clavien-Dindo classification of Grade II or higher. Survival and pneumonia incidence were compared using the Kaplan-Meier method. Logistic regression analysis was used to examine the relationship between these variables and POP. The study included 513 patients, of which 441 were men. POP occurred in 86 patients (16.7%). When all patients were stratified by %PEF into two groups, the group with %PEF lower that 80% had significantly poorer prognosis and higher incidence of pneumonia. Multivariable logistic regression analysis indicated that %PEF (OR: 0.986, 95%CI: 0.974-0.999, P = 0.030), along with age, BMI, preoperative treatment, and recurrent laryngeal nerve palsy were independent protective factors against POP. These results reveal that %PEF predicts the development of POP following esophagectomy for esophageal cancer.

Gastric conduit reconstruction after esophagectomy.

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations.

Laparoscopic right gastroepiploic artery-sparing distal gastric tube resection with lymph node dissection for gastric tube cancer after esophagectomy: A novel surgical approach (with video).

Total resection of the gastric tube with lymphadenectomy for advanced gastric tube cancer is highly invasive and associated with severe complications. Other surgical option, partial gastrectomy or wedge resection, is insufficient if lymph node metastasis is suspected. Therefore, a technique balancing invasiveness and curability is required. First, we laparoscopically peeled off adhesions of the gastric tube, gastric mesentery (including the right gastroepiploic artery/vein), pericardial membrane, and aorta, up to the planned resection line. Subsequently, we cut the infrapyloric and right gastric arteries at their roots and dissected No. 5 and No. 6 lymph nodes. We taped and spared the right gastroepiploic artery and vein and dissected the tissues including No. 4d lymph nodes. Finally, the gastric tube was cut using a linear stapler, and the remaining gastric tube was anastomosed to the jejunum with a circular stapler. The mean operative time for the three cases treated using this intervention was 729 min. The patients were discharged on postoperative day 8 or 9 without any complications. They all remained alive and recurrence-free. This novel approach balances invasiveness and curability by leveraging the advantages of laparoscopy. The procedure was performed safely and reproducibly in three consecutive cases, providing another viable option for the treatment of gastric tube cancer.

Reconstruction in early squamous cell carcinoma of the oral cavity—Do free flaps improve oncological outcome?

BackgroundOral squamous cell carcinoma (OSCC) ranks on position 14 in global cancer analysis and makes up to 38 % of all head and neck squamous cell carcinomas. While surgery is accepted as first-line treatment of early tumors, the reconstructive approach is not standardized. Therefore, we evaluated the concept of ablative tumor removal and microvascular reconstruction in terms of oncological safety and surgical morbidity for early OSCCs. Methods262 patients received ablative tumor surgery with neck dissection together with microvascular reconstruction between 2010 and 2020. General clinical data was analyzed descriptively with regard to surgery time, duration of tracheotomy and hospitalization. ResultsEstimated 5-year overall and progression-free survival was 85 % and 77 % respectively with no significant difference between stage I or II cancer patients. Tracheotomy was performed in 131 patients (50 %). 19 patients (7.3 %) were temporarily dependent to a gastric feeding tube. Flap loss occurred in 9 patients (3.4 %). DiscussionIn a standardized setting, mean surgery time could be reduced constantly. We propose consistent tumor ablation, combined with elective neck dissection and microvascular reconstruction in early oral squamous cell carcinoma. The presented concept leads to excellent oncological and functional results with acceptable morbidity and short surgery times.

Nivolumab-induced Thrombotic Thrombocytopenic Purpura in Patients with Gastric Tube Cancer.

Recently, immune checkpoint inhibitors (ICIs) have been used to treat several cancer types. ICIs have been reported to cause a wide variety of immune-related adverse events, including endocrine, neurologic, gastrointestinal, and cutaneous disorders. Thrombotic thrombocytopenic purpura (TTP) is an autoimmune hematologic disorder characterized by the presence of autoantibodies against a disintegrin and metalloprotease with thrombospondin-1, member 13. Several previous cases of TTP were thought to have been caused by ICI treatment. We herein report a rare case of TTP that developed after long-term treatment with an ICI (nivolumab) for gastric tube cancer.

Liver transplantation plus chemotherapy versus chemotherapy alone in patients with permanently unresectable colorectal liver metastases (TransMet): results from a multicentre, open-label, prospective, randomised controlled trial

Despite the increasing efficacy of chemotherapy, permanently unresectable colorectal liver metastases are associated with poor long-term survival. We aimed to assess whether liver transplantation plus chemotherapy could improve overall survival. TransMet was a multicentre, open-label, prospective, randomised controlled trial done in 20 tertiary centres in Europe. Patients aged 18-65 years, with Eastern Cooperative Oncology Group performance score 0-1, permanently unresectable colorectal liver metastases from resected BRAF-non-mutated colorectal cancer responsive to systemic chemotherapy (≥3 months, ≤3 lines), and no extrahepatic disease, were eligible for enrolment. Patients were randomised (1:1) to liver transplantation plus chemotherapy or chemotherapy alone, using block randomisation. The liver transplantation plus chemotherapy group underwent liver transplantation for 2 months or less after the last chemotherapy cycle. At randomisation, the liver transplantation plus chemotherapy group received a median of 21·0 chemotherapy cycles (IQR 18·0-29·0) versus 17·0 cycles (12·0-24·0) in the chemotherapy alone group, in up to three lines of chemotherapy. During first-line chemotherapy, 64 (68%) of 94 patients had received doublet chemotherapy and 30 (32%) of 94 patients had received triplet regimens; 76 (80%) of 94 patients had targeted therapy. Transplanted patients received tailored immunosuppression (methylprednisolone 10 mg/kg intravenously on day 0; tacrolimus 0·1 mg/kg via gastric tube on day 0, 6-10 ng/mL days 1-14; mycophenolate mofetil 10 mg/kg intravenously day 0 to <2 months and switch to everolimus 5-8 ng/mL), and postoperative chemotherapy, and the chemotherapy group had continued chemotherapy. The primary endpoint was 5-year overall survival analysed in the intention to treat and per-protocol population. Safety events were assessed in the as-treated population. The study is registered with ClinicalTrials.gov (NCT02597348), and accrual is complete. Between Feb 18, 2016, and July 5, 2021, 94 patients were randomly assigned and included in the intention-to-treat population, with 47 in the liver transplantation plus chemotherapy group and 47 in the chemotherapy alone group. 11 patients in the liver transplantation plus chemotherapy group and nine patients in the chemotherapy alone group did not receive the assigned treatment; 36 patients and 38 patients in each group, respectively, were included in the per-protocol analysis. Patients had a median age of 54·0 years (IQR 47·0-59·0), and 55 (59%) of 94 patients were male and 39 (41%) were female. Median follow-up was 59·3 months (IQR 42·4-60·2). In the intention-to-treat population, 5-year overall survival was 56·6% (95% CI 43·2-74·1) for liver transplantation plus chemotherapy and 12·6% (5·2-30·1) for chemotherapy alone (HR 0·37 [95% CI 0·21-0·65]; p=0·0003) and 73·3% (95% CI 59·6-90·0) and 9·3% (3·2-26·8), respectively, for the per-protocol population. Serious adverse events occurred in 32 (80%) of 40 patients who underwent liver transplantation (from either group), and 69 serious adverse events were observed in 45 (83%) of 54 patients treated with chemotherapy alone. Three patients in the liver transplantation plus chemotherapy group were retransplanted, one of whom died postoperatively of multi-organ failure. In selected patients with permanently unresectable colorectal liver metastases, liver transplantation plus chemotherapy with organ allocation priority significantly improved survival versus chemotherapy alone. These results support the validation of liver transplantation as a new standard option for patients with permanently unresectable liver-only metastases. French National Cancer Institute and Assistance Publique-Hôpitaux de Paris.

Pancreatoduodenectomy after Ivor-Lewis Santi oesophagectomy with gastric tube reconstruction. An European multicentre experience

BackgroundPancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes. MethodsWe have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes. ResultsEight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14–24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases. ConclusionPerforming pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed.

Characteristics of the hemomicrocirculatory channel of the ventricular myocardium in triptorelin-induced central deprivation of the synthesis of luteinizing hormone and correction of this condition by the introduction of quercetin

The study of the microcirculatory channel of the connective tissue of the myocardium of the ventricles improves the understanding of the features of pathological processes, such as ischemia, hypoxia and remodeling of the myocardium, the evaluation of the effectiveness of drug therapy, as well as rehabilitation methods. The purpose of the study is to determine the changes in the hemomicrocirculatory channel of the ventricular myocardium in triptorelin-induced central deprivation of the synthesis of luteinizing hormone and the correction of this condition by the introduction of quercetin. The experiment was conducted on 60 sexually mature white male rats weighing 140-160 g. The rats were divided into 3 groups. 1 group – control, rats injected with physiological solution (10 animals). Group 2 – rats that were injected subcutaneously with diphereline (triptorelin embonate) at a dose of 0.3 mg of the active substance per kg of body weight for 365 days (25 animals). Group 3 – rats that were injected with a solution of triptorelin at the rate of 0.3 mg of the active substance per kg of body weight to simulate central deprivation of the synthesis of luteinizing hormone with the addition of quercitin to the diet using a gastric tube based on the body weight of the animals three times a week (25 animals). Animals were withdrawn from the experiment after 1, 3, 6, 9 and 12 months by overdose with ether anesthesia. A comprehensive study of histological preparations of the myocardium and quantitative calculation of the diameter of the vessels of the microcirculatory bed were carried out using a light microscope with a digital microfilter and software adapted for these studies. Statistical processing of the research results was carried out using the Microsoft Office Excel software and the Real Statistics 2019 extension. When analyzing the index of arteriole diameters in the group of animals that were injected with triptorelin after 1, 3, 6, 9 and 12 months, a significant increase in the diameter of arterioles was established compared to the control group animals, respectively, by 13.9 % – 40.8 % – 102.6 % – 112.6 % – 11.5 %; and in animals to which quercetin was administered against the background of triptorelin administration, it was established that this indicator after 1 month did not reliably differ from the similar one in the control group, and after 3, 6, 9 and 12 months it was reliably higher than in the control respectively by 11.5 % – 136.2 % – 101.1 % – 101.4 %. The analysis of the diameters of the venular link of the hemomicrocirculatory channel in the group of animals administered triptorelin showed a significant increase in the value of this indicator after 3, 6, 9 and 12 months compared to the control group, respectively by 20.0 % – 71.2 % – 57.8 % – 22.9 %; and in animals that were additionally injected with quercetin after 1 month, the diameter of venules was significantly reduced by 8.1% compared to the control, and after 3, 6, 9 and 12 months – respectively by 5.2 % – 87.5 % – 64.0 % – 50.4 % it was significantly greater than in control animals. Analysis of capillary diameters in the group of animals administered triptorelin showed a significant increase in the value of this indicator after 1, 3, 6 and 9 months compared to the control group, respectively by 23.9 % – 49.1 % – 61.8 % – 36.7 %; and in animals that were additionally injected with quercetin, the capillary diameter significantly increased compared to the control after 3, 6, 9, and 12 months – by 22.3 % – 55.3 % – 17.1 % – 25.2 %, respectively. The conducted study showed that the introduction of triptorelin leads to structural and functional changes in the components of the microcirculatory channel of the myocardium of the ventricles of the heart, which are characterized by changes in the diameter of the arterial and venous links with a gradual increase in blood flow, the maximum of which is at the 6th month of the experiment in both experimental groups, but without impaired outflow in the group with the addition of quercitin.