History Of Distal Gastrectomy Research Articles

Segmental cervical esophagectomy with free jejunal flap reconstruction for cervical esophageal cancer in patients with previous history of gastric surgery: a report of two cases.

Although free-flap jejunal reconstruction is frequently performed after cervical esophagectomy for cervical esophageal cancer, the procedure after gastric surgery has not been reported. We encountered two patients with esophageal cancer and previous gastric surgeries who eventually underwent segmental esophagectomy with free-flap jejunal reconstruction. Case one involved a 75-year-old man who underwentabdominal abscess and duodenal ulcer perforation surgeries (abdominal drainage and subsequent gastrojejunal bypass). A type 0-IIa tumor was located posterior to the cervical esophagus's right wall, 21cm from the incisor, without lymph node swelling or distant metastasis. The left lobe of the thyroid gland was mobilized to ensure an oral resection margin. Severe abdominal adhesions required careful adhesiolysis to harvest the jejunum (20cm long) 40cm from the jejunojejunostomy. An end-to-side and side-to-end esophagojejunostomy were performed for the proximal and distal ends, respectively. Case two involved a 75-year-old male with a history of distal gastrectomy with Billroth I reconstruction for early gastric cancer. A submucosal tumor-like lesion was located on the cervical esophageal wall on the left side, 21cm from the incisor. The distal esophagus requiredadditional segmental resection because the anal resection line was close to the tumor. Jejunum (10cm long) 30cm from Ligament of Treitz was harvested. An end-to-side and end-to-end esophagojejunostomy for the proximal and distal ends, respectively, was performed. This surgery requires a thorough preoperative examination to ensure an adequate surgical margin and a careful free-flap harvest based on post-gastric surgery anatomy.

Safety and efficacy of double-tract reconstruction with remnant stomach conservation in esophagectomy for patients with a history of distal gastrectomy.

Total gastrectomy with jejunum or colon reconstruction after esophagectomy is commonly performed in patients with esophageal cancer who have a history of distal gastrectomy. In this study, we examined the safety and effectiveness of double-tract reconstruction (DTR) with preservation of the remnant stomach for said patient population. Twenty-seven esophageal cancer patients with a history of distal gastrectomy who underwent transthoracic esophagectomy between 2010 and 2020 in our institution were retrospectively analyzed; 15 of these patients underwent DTR, whereas 12 underwent completion gastrectomy with jejunal Roux-en-Y reconstruction (RYR). Short-term outcomes, postoperative nutritional indexes, and ghrelin levels were evaluated. Moreover, abdominal lymph-node metastasis and recurrence, which were removed by total residual gastrectomy, were examined to determine the oncological validity of residual stomach preservation. There was no metastasis and recurrence in abdominal lymph nodes, such as #4sa or #11d, which were removed by total residual gastrectomy. Total operation time did not differ between the groups (P = 0.4247). The blood loss for the DTR group was 495 ± 446mL, whereas that for the RYR group was 844 ± 575mL (P = 0.0168). Clavien-Dindo grade III or higher complications were not significantly different between the groups (P = 0.7063). The rates of serum total protein values at 6months in the DTR and RYR groups were 112% ± 12.2% and 102.6% ± 10.7% (P = 0.0403), respectively. The prognostic nutritional indexes at 6months in the DTR and RYR groups were 108.6% ± 14.5% and 83.2% ± 42.6% (P = 0.0376), respectively. DTR in esophagectomy is safe and effective for patients with a history of distal gastrectomy.

The Application of Two-Stage Operation for High-Risk Patients with Oesophageal Cancer Following Gastrectomy

BackgroundOesophageal replacement by colonic interposition remains a major challenge due to its complexity and high incidence of complications; here we applied the two-stage operation strategy to oesophageal replacement by colonic interposition in high-risk oesophageal cancer patients following gastrectomy. MethodsWe performed a retrospective analysis on the data of patients with a history of distal gastrectomy who underwent one-stage and two-stage oesophageal replacement by colonic interposition from February 2012 to February 2020, and explored the relationship between the staging strategy and postoperative outcomes. ResultsThe clinical data of 93 patients were collected and analysed. There were no significant differences in the patients’ characteristics between the two groups (all p > 0.05), except for comorbidities and Charlson Comorbidity Index (all p < 0.05). The Clavien–Dindo score between the two groups was also not significantly different (p > 0.05). The logistic regression models revealed that patients who had received preoperative therapy had a higher Clavien–Dindo score (p < 0.05), but the stage strategy did not (p > 0.05). ConclusionsThe two-stage operation is feasible in high-risk patients who need to undergo colonic interposition for oesophageal replacement. At the same time, it lowers the technical threshold of colonic interposition for oesophageal replacement, increasing this surgical technique’s acceptability.

Outcomes of endoscopic submucosal dissection for gastroesophageal reflux disease (ESD-G) for medication-refractory gastroesophageal reflux disease: 35 cases underwent ESD-G including 15 cases followed more than 5\xa0years

BackgroundAlthough some kinds of endoluminal surgery for patients with proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) have been reported, there are few reports on their long-term outcomes. In 2014, we reported the effectiveness of endoscopic surgery for PPI-refractory GERD, which we invented and named endoscopic submucosal dissection for GERD (ESD-G) in 2008. Thereafter, we accumulated more cases and monitored the patients’ condition postoperatively and describe the outcomes herein.Patients and methodsThis single-center, single-arm trial was conducted at the Osaka Medical and Pharmaceutical University Hospital. We compared outcomes between before and 3–6 months after ESD-G. Additionally, we investigated the outcomes of patients 5 or more years after ESD-G.ResultsWe performed 42 ESD-G procedures in 35 patients between 2008 and 2020. In seven patients, ESD-G was performed twice for various reasons. The frequency scale for the symptoms of GERD score was significantly improved 3–6 months after ESD-G (22 → 10, p < 0.0001); the Los Angeles classification for reflux esophagitis was clearly improved after ESD-G (p = 0.0423). The number of reflux episodes was not decreased by ESD-G. There was a significant difference in the potency unit of gastric acid secretion suppressants for controlling GERD-related symptoms between baseline and 3–6 months after ESD-G (p = 0.0009). In patients without a history of distal gastrectomy who underwent ESD-G, the potency unit of gastric acid secretion suppressants significantly decreased 5 or more years after ESD-G (p = 0.0121).ConclusionESD-G may be effective in patients with refractory GERD-related symptoms without a history of distal gastrectomy.

Per-oral endoscopic myotomy for esophageal achalasia following distal gastrectomy

The patient was a male in his 70s with a history of distal gastrectomy and Billroth-I reconstruction. He was suspected of having esophageal achalasia and was started on calcium blockers in X-2 year. The symptoms worsened, and he presented to our hospital in X year. We diagnosed esophageal achalasia (Chicago classification ver. 3.0;type I), and conducted per-oral endoscopic myotomy (POEM). His postoperative course was uneventful with no postoperative symptoms. In cases of esophageal achalasia following distal gastrectomy, it is important to consider adhesions, mobility of the remaining stomach, and preservation of the short gastric artery and vein. Since the Heller-Dor operation can be difficult, POEM may be a reasonable alternative in these cases.

Reconstruction of the esophagus of patients with middle thoracic esophageal carcinoma using the remnant stomach following Billroth II gastrectomy.

It seems impossible to reconstruct the esophagus of patients with middle thoracic esophageal carcinoma with a history of distal gastrectomy using the remnant stomach. Although surgeons have made multiple efforts to reconstruct the esophagus using the remnant stomach, it can only be successfully used in cases of lower thoracic esophageal cancer. Additionally, the surgery is more complex than traditional esophagogastrostomy due to challenges including mobilization of the remnant stomach with the spleen and transposition of the pancreatic tail into the left hemithorax. Our operation proved that the remnant stomach, which we named as the completely mobilized remnant stomach after dissection of the feeding vessels, remained viable. We successfully integrated the completely mobilized remnant stomach in the reconstruction of the lower thoracic esophageal tract and then integrated it in Ivor Lewis esophagogastrostomy. We describe this new alternative surgical technique for the treatment of middle thoracic esophageal carcinoma in patients with a history of distal gastrectomy in this study. Clinical data of 23 patients from 2008 to 2019 were retrospectively analyzed. All patients underwent the Ivor Lewis procedure. All remaining vessels of the remnant stomach were dissected at their origins, and Roux-en-Y reconstruction or Braun anastomosis was performed. After esophagectomy during right thoracotomy, anastomosis of the remnant stomach and esophagus was performed. Two-field lymph node dissections were performed. There was no case of necrosis of the remnant stomach or of perioperative death. Serious complications included anastomotic leak in three cases, afferent-efferent loop syndrome in one, and anastomotic stricture in two. Application of the completely mobilized remnant stomach in Ivor Lewis esophagogastrostomy is feasible, and the surgical procedure is similar to that of normal esophagogastrostomy.

Feasibility of preserving the remnant stomach during distal pancreatectomy after distal gastrectomy.

The safety and feasibility of preserving the remnant stomach during distal pancreatectomy (DP) in patients who have undergone distal gastrectomy (DG) remains unclear. A retrospective review of a prospectively maintained database was performed to identify patients who underwent DP. A propensity score-matched analysis was performed to match post-DG patients with control patients. Among the 226 patients included in this study, 9 DP patients who had a history of DG were studied (4.0%). These nine patients in the DG group were matched to 45 patients in the control group. There were no significant differences in the incidence of postoperative morbidities, including postoperative pancreatic fistula rate or stomach-related complications. The hemoglobin A1C (HbA1c) levels in the DG group after surgery decreased to the normal range. Our study suggested that the remnant stomach may be safely preserved when performing DP in patients with a history of DG with respect to short-term morbidities. However, there are some concerns about the long-term nutritional status in patients with a history of DG.

Clinicopathologic features of remnant gastric cancer after curative distal gastrectomy according to previous reconstruction method: a retrospective cohort study

BackgroundSurvival rate of patients treated for gastric cancer has increased due to early detection and improvements of surgical technique and chemotherapy. Increase in survival rate has led to an increase in the risk for remnant gastric cancer (RGC). The purpose of this study was to investigate clinicopathologic features of RGC according to previous reconstruction method and factors affecting the interval from previous curative distal gastrectomy for gastric cancer to RGC occurrence.MethodsMedical records of patients diagnosed with RGC at Yeungnam University Medical Center from January 2000 to December 2017 who had a history of distal gastrectomy with D2 LN dissection due to gastric cancer were reviewed retrospectively.ResultsForty-eight patients were enrolled in this study. The mean interval of 48 RGC patients was 105.6 months (8.8 years). RGC after Billroth II reconstruction recurred more often at anastomosis site than RGC after Billroth I reconstruction (p = 0.001). The mean interval of RGC after Billroth I reconstruction was 67 months, shorter than 119 months of RGC after Billroth II reconstruction (p = 0.003). On the contrary, interval showed no difference according to stage of previous gastric cancer, remnant gastric cancer, or sex (p = 0.810, 0.145, and 0.372, respectively).ConclusionsRGC after Billroth I reconstruction tends to arise earlier at non-anastomosis site than RGC after Billroth II. Therefore, we should examine non-anastomosis site carefully from the beginning of surveillance after gastric cancer surgery with Billroth I reconstruction for better outcome.

A case of volvulus of the small intestine with chylous ascites in which strangulation was successfully relieved using a long intestinal tube: A case report

Background:Chylous ascites has been uncommonly observed with bowel obstruction. This unusual phenomenon may be secondary to various disease processes with a correct diagnosis seldom made preoperatively.&#x0D; Case presentation: The patient was a 64-year-old man with a medical history of distal gastrectomy for gastric cancer over 30 years ago. We diagnosed him with internal volvulus by several examinations and decided to perform emergency laparotomy. His abdominal pain improved markedly after inserting a long intestinal tube. At laparotomy, there was a large amount of chylous ascites in the abdomen. Despite an edematous small intestine with prominent lymphatic vessels, the cause of the volvulus was unclear, and there was also no evidence of ischemic change in the small intestine. A biochemical analysis of the peritoneal fluid revealed elevated values of triglyceride levels.&#x0D; Conclusion:We experienced a case of volvulus of the small intestine with chylous ascites in which strangulation was successfully relieved using a long intestinal tube.

PS01.157: APPLICATION OF THE COMPLETELY MOBILIZED REMNANT STOMACH IN ESOPHAGOPLASTY FOR LOWER THORACIC ESOPHAGEAL CARCINOMA FOLLOWING DISTAL GASTRECTOMY

Abstract Background Reconstruction of the esophagus for the patients following distal gastrectomy (DGE)is a significant challenge for surgeons. Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE. Methods The clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II. Results No perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4). Conclusion The completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication. Disclosure All authors have declared no conflicts of interest.

Hiatal hernia involving prolapse of the entire stomach into the mediastinum after distal gastrectomy: a case report

BackgroundProlapse of a small part of the proximal stomach through the hiatus into the mediastinum is relatively common. Hiatal hernia involving the postoperative stomach has been reported previously, but the degree of hernia was not so severe, and hiatal hernia involving the prolapse of the entire stomach following gastrectomy into the mediastinum has never been reported. We describe a very rare case of large hiatal hernia involving the entire postoperative stomach.Case presentationA 79-year-old man with a history of distal gastrectomy for submucosal benign tumor 40 years ago was referred to our hospital because of dysphagia and weight loss. Computed tomography revealed prolapse of the entire postoperative stomach into the mediastinum, and a radical operation was performed. There was a strong adhesion in the hernial sac of the mediastinum, but only little adhesion due to a previous open surgery in the abdominal cavity was present. After the stomach was pulled into the abdominal cavity, suture cruroplasty and Toupet fundoplication without dissection of the short gastric artery were performed. The patient experienced postoperative paralytic ileus, but the rest of the postoperative course was uneventful and the symptom of dysphagia improved.ConclusionsWe presented a very rare large hiatal hernia involving the entire postoperative stomach. Toupet fundoplication preserving the short gastric artery could be one of the optimal surgeries to prevent postoperative regurgitation of the remnant stomach.

The completely mobilized remnant stomach: A new choice to reconstruct the esophagus in lower thoracic esophageal carcinoma with a history of distal gastrectomy

ObjectiveIt is a significant surgical challenge to reconstruct esophagus for the patients following distal gastrectomy (DGE). Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE. MethodsThe clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II. ResultNo perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4). ConclusionThe completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication.

Risk Factors for an Iatrogenic Mallory-Weiss Tear Requiring Bleeding Control during a Screening Upper Endoscopy.

Background and Aim. In some cases of iatrogenic Mallory-Weiss tears (MWTs), hemostasis is needed due to severe mucosal tearing with bleeding. Therefore, we aimed to evaluate the risk factors for severe iatrogenic MWTs and the methods of endoscopic bleeding control. Materials and Methods. Between January 2008 and December 2012, 426,085 cases of screening upper endoscopy were performed at the Asan Medical Center. We retrospectively analyzed the risk factors for severe iatrogenic MWTs requiring an endoscopic procedure and the treatment modalities of bleeding control. Results. Iatrogenic MWTs occurred in 546 cases (0.13%) of screening upper endoscopy in 539 patients. Bleeding control due to severe bleeding was applied in 71 cases (13.0%), and rebleeding after initial bleeding control occurred in 1 case. Multivariate analysis showed that old age, a history of distal gastrectomy, and a less-experienced endoscopist (fewer than 2,237.5 endoscopic procedures at the time of the MWT) were associated with severe iatrogenic MWTs requiring an endoscopic procedure. Among 71 cases requiring bleeding control, a hemoclip was used in 81.7% (58 cases). Conclusions. Screening endoscopy procedures should be carefully performed when patients are in their old age and have a history of distal gastrectomy, particularly if the endoscopist is less experienced.

内視鏡的破砕術およびコーラ溶解療法後，落下による腸閉塞を発症した柿胃石の1例

A 71-year-old man with a history of distal gastrectomy (Billroth-I reconstruction) presented to our hospital with frequent vomiting and was hospitalized. On the third day after admission, an upper endoscopy showed gastric bezoars in the descending portion of the duodenum, hence we performed endoscopic lithotripsy, but it failed to achieve complete crushing, and cola dissolution therapy was initiated via the gastric tube. Similarly, on the eighth day after admission, we performed an additional endoscopic lithotripsy but failed to achieve complete crushing. An ileus tube was then placed and cola dissolution therapy was continued. On the eleventh day after admission, the patient complained of abdominal pain, and abdominal CT scan revealed that ascites appeared around the liver and the bezoars had migrated to the distal jejunum. Further conservative treatment was considered difficult, so the bezoars were removed by performing an emergency surgery. There are reports suggesting that surgery for intestinal obstruction caused by bezoars could be avoided by dissolution therapy with cola via an ileus tube, while other reports indicate that intestinal necrosis may occur during dissolution therapy. Therefore, it is important to carefully judge the indications for dissolution therapy and not miss the timing of surgery.

Successful management of esophageal perforation using a removable self-expanding covered metallic stent after endoscopic submucosal dissection for a patient with a history of gastrectomy

An 81-year-old man with esophageal perforation after endoscopic submucosal dissection, who had a history of distal gastrectomy and had undergone endoscopic submucosal dissection for high-grade intraepithelial dysplasia at another hospital, suddenly developed epigastric pain at night after vomiting. Computed tomography showed pneumomediastinum and bilateral pleural effusions indicating esophageal perforation. The initial doctor referred the patient to our department. On arrival, the patient was in septic shock with acute respiratory failure. It was considered that he was unable to undergo aggressive surgical treatment safely, and a stent with a silicone cover and check valve was placed. Drainage tubes were then inserted into the mediastinum and each thoracic cavity, and a double elementary diet tube was inserted for nutrition and decompression of the stomach. The stent was removed on the 26th day, and the perforation was cured. Stent insertion is a useful treatment for the patient with serious esophageal perforation after ESD with a history of gastrectomy.

Benign Biliary Strictures: Diagnostic Evaluation and Approaches to Percutaneous Treatment

Interventional radiologists are often consulted to help identify and treat biliary strictures that can result from a variety of benign etiologies. Mainstays of noninvasive imaging for benign biliary strictures include ultrasound, contrast-enhanced computed tomography and magnetic resonance imaging, magnetic resonance cholangiopancreatography, and computed tomography cholangiography. Endoscopic retrograde cholangiography is the invasive diagnostic procedure of choice, allowing both localization of a stricture and treatment. Percutaneous biliary interventions are reserved for patients who are not candidates for endoscopic retrograde cholangiography (eg, history of distal gastrectomy and biliary-enteric anastomosis to a jejunal roux limb). This review discusses the roles of percutaneous transhepatic cholangiography and biliary drainage in the diagnosis of benign biliary strictures. The methodology for crossing benign biliary strictures, approaches to balloon dilation, management of recalcitrant strictures (ie, large-bore biliary catheters and retrievable covered stents), and the expected outcomes and complications of percutaneous treatment of benign biliary strictures are also addressed.

Esophagogastric reconstruction using remnant stomach with a single vessel pedicel: Technique and outcomes.

Esophageal cancer with a history of distal gastrectomy is a clinical problem. To our knowledge there have been no reports of remnant stomach fed from the left gastroepiploic artery being used in esophageal reconstruction. We, herein, report four cases of esophagogastric reconstruction using remnant stomach with a single left gastroepiploic vascular pedicel. It is more functional to use the remnant stomach than other replacements. Meanwhile, the gastric conduit fed from the left gastroepiploic artery showed sufficient vascularity and stable gastroesophageal anastomosis. The technique and outcomes in follow-up have proven feasible and save time.

History of distal gastrectomy prevents metabolic syndrome and chronic kidney disease

AimsChronic kidney disease (CKD) due to metabolic syndrome has recently become a social problem in Japan. In this report, the associations between the history of distal gastrectomy (DG) and the incidence of metabolic syndrome or CKD were evaluated. MethodsArteriosclerosis-related factors were compared among patients with a history of DG who were <70 years old (n=41) and controls selected at random (n=410) after matching for age and sex. ResultsThe patients with a history of DG were less obese than controls and had lower low-density lipoprotein cholesterol and higher high-density lipoprotein cholesterol serum levels. Furthermore, they had an excellent estimated glomerular filtration rate, which was used as an index of CKD. ConclusionsThese findings suggest that a history of DG prevents metabolic syndrome and reduces the risk of CKD.

A Case of Sudden Onset Septicemia in Recurred Gastric Cancer Following S1 Plus Docetaxel Treatment

Pyogenic liver abscess in patients with malignant disease is a fatal state and is easily diagnosed. We presented a rare case of sudden fatal septicemia following anticancer treatment for recurred gastric cancer due to multiple liver abscesses which could not be diagnosed. A 72-year-old male with recurred gastric cancer received anticancer agents. He had a history of distal gastrectomy with right hepatic lobectomy for hepatic metastasis. He received anticancer treatment in the outpatient's service center periodically, and his performance status was preserved with nothing in particular. After administrating docetaxel, he suddenly developed septicemia and multiple organ failure and died 5 days after strong medical supports. Pathological autopsy revealed that multiple minute abscesses of the liver which could not be detected macroscopically were the causes of fatal septicemia. The etiology, therapies and prognosis of rare entity are being discussed.

Anterior vs. posterior mediastinal routes in colon interposition after esophagectomy.

Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.