Post Gastrectomy Research Articles

A novel dynamic Bayesian network approach for data mining and survival data analysis

BackgroundCensorship is the primary challenge in survival modeling, especially in human health studies. The classical methods have been limited by applications like Kaplan–Meier or restricted assumptions like the Cox regression model. On the other hand, Machine learning algorithms commonly rely on the high dimensionality of data and ignore the censorship attribute. In addition, these algorithms are more sophisticated to understand and utilize. We propose a novel approach based on the Bayesian network to address these issues.MethodsWe proposed a two-slice temporal Bayesian network model for the survival data, introducing the survival and censorship status in each observed time as the dynamic states. A score-based algorithm learned the structure of the directed acyclic graph. The likelihood approach conducted parameter learning. We conducted a simulation study to assess the performance of our model in comparison with the Kaplan–Meier and Cox proportional hazard regression. We defined various scenarios according to the sample size, censoring rate, and shapes of survival and censoring distributions across time. Finally, we fit the model on a real-world dataset that includes 760 post gastrectomy surgery due to gastric cancer. The validation of the model was explored using the hold-out technique based on the posterior classification error. Our survival model performance results were compared using the Kaplan–Meier and Cox proportional hazard models.ResultsThe simulation study shows the superiority of DBN in bias reduction for many scenarios compared with Cox regression and Kaplan–Meier, especially in the late survival times. In the real-world data, the structure of the dynamic Bayesian network model satisfied the finding from Kaplan–Meier and Cox regression classical approaches. The posterior classification error found from the validation technique did not exceed 0.04, representing that our network predicted the state variables with more than 96% accuracy.ConclusionsOur proposed dynamic Bayesian network model could be used as a data mining technique in the context of survival data analysis. The advantages of this approach are feature selection ability, straightforward interpretation, handling of high-dimensional data, and few assumptions.

Spontaneous Gastric Intramural Hematoma: Case Report and Literature Review

Spontaneous gastric intramural hematoma is a rare disease. Herein, we present a case of a previously healthy 28-year-old male patient who presented with diarrhea and diffuse abdominal pain of one-week duration. The patient was diagnosed with spontaneous gastric intramural hematoma post urgent partial gastrectomy for a bleeding gastric tumor. Six other cases of spontaneous gastric intramural hematoma are published in the literature; therefore, when encountering a case of intra-abdominal mass attached to the gastric wall, gastric intramural hematoma should be considered in the differential even when no cause is present.

P-OGC11 Vitamin B12 supplementation post gastrectomy. A service audit in St. James’s hospital, Dublin

Abstract Background Vitamin B12 deficiency is a well described complication post gastrectomy. It is caused by the loss of parietal cell mass leading to megaloblastic anaemia and possible long term neurological symptoms. Treatment can be with standardised replacement regimens or to monitor B12 levels and replace as required. This study assesses patient understanding of and compliance with B12 supplementation guidelines post total and subtotal gastrectomy. Methods 125 patients who underwent gastrectomy between 2010-2020 were available for study (86 total gastrectomies, 39 subtotal gastrectomies). Patient data was collected by review of the hospital electronic records and individual phone calls. Patients were asked standardised questions to elicit knowledge of the importance of B12 supplementation and compliance with supplementation. Results 92% (79/86) of total gastrectomy patients reported compliance in regular parenteral B12 supplementation. Compliance was significantly lower for subtotal gastrectomies for checking and/or replacing their vitamin B12 at 53.8% (21/39) (p < 0.001). 62.6% of patients stated that they knew it was important to supplement B12 post gastrectomy. 37.8% of participants could explain why this was important and 14.8% had any knowledge of the complications of vitamin B12 deficiency. Patients who were compliant with B12 supplementation had an improved understanding of why supplementation was important compared to those who did not. Conclusions Regular monitoring and supplementation of vitamin B12 levels is important post gastrectomy. This study demonstrates good compliance in those undergoing total gastrectomy. Patient understanding correlates with compliance, suggesting that patient education and knowledge reinforcement may be key to compliance with vitamin B12 supplementation.

2183 Endoscopic Management of Efferent Loop Syndrome Using Axios Lumen-Apposing Metal Stent

INTRODUCTION: Efferent loop syndrome (ELS) is a rare post gastrectomy syndrome that can occur following Billroth-II or Roux-en-Y reconstruction. The most common loop syndrome after gastric surgery is afferent loop syndrome (ALS), however efferent loop syndrome has been reported. ELS may occur due to a mechanical obstruction of the efferent limb due to an anastomotic stricture, malignancy, volvulus, intussusception, internal hernia or abdominal adhesion after surgery. Presentations include abdominal distension and vomiting and rarely pancreatitis or cholangitis. We present a case of efferent loop syndrome managed with an Axios lumen apposing metal stent (LAMS). CASE DESCRIPTION/METHODS: 79 year-old male with a history of gastric adenocarcinoma status post distal gastrectomy with Billroth-II reconstruction one month prior to admission presented with abdominal pain and nausea. Computed tomography of the abdomen revealed distended stomach with contrast, dilated biliary limb with collapsed distal jejunum and no passage of contrast distal to the anastomosis (Image 1). Upper endoscopy (EGD) revealed a friable gastrojejunostomy anastomosis with a patent afferent limb and a nearly obstructed stenosis at the efferent limb suture line. A 20 × 10 mm A-LAMS was deployed across the stenosed efferent limb under direct visualization and fluoroscopic guidance (Images 2 and 3). Follow up upper gastrointestinal series confirmed brisk passage of contrast into the efferent limb. The patient clinically improved and a repeat EGD revealed a patent efferent limb and a dislodged Axios LAMS which was endoscopically removed. DISCUSSION: ELS and ALS can be managed surgically or endoscopically. Endoscopic options include dilation and enteral stenting. Dilation may require multiple sessions and stenting utilizing self-expanding metallic stents (SEMS) may be limited by tumor in-growth in the setting of malignant obstruction. LAMS creates a de-novo fistulous tract to bypass an obstruction while its saddle shape provides anti-migratory properties and allows apposition of two gastrointestinal lumens. While LAMS has been reported in ALS, there are only rare reports in the management of ELS. Our case highlights a case of successful management of ELS with Axio LAMS.

MON-145 An Unusual Cause of Hypoglycemia in a Non-Diabetic Elderly Male

Introduction: Hypoglycemia (HYPO) in non-diabetic patients is an unusual scenario and presents a diagnostic challenge, resulting in serious consequences for patients. We describe the case of an elderly non-diabetic male who developed severe persistent HYPO. Case: A 78-year-old male with history of macroprolactinoma taking bromocriptine, Hashimoto's hypothyroidism, initially treated with low dose L-thyroxine, followed by Graves' hyperthyroidism, Parkinson’s disease (PD), osteopenia was noted to have hypoglycemia (54 mg/dL) on routine lab work. When questioned, he admitted to having had years of lightheaded episodes, "feeling jittery", which improved within minutes after eating sugary foods. His wife mentioned that he “loved to eat sweets” and high simple carbohydrate meals(CARBS). Physical exam - orthostatic hypotension and mild resting tremors, both attributed to PD. Continuous glucose monitoring (CGMS) was performed for 2 weeks which documented HYPO overnight while sleeping, fasting and between meals. The HYPO was associated more frequently with sweet bedtime snacks. Laboratory- Glucose tolerance test was stopped due to HYPO with symptoms. ACTH=19 pg/mL (nl 0-47), AM Cortisol 19.4 microg/dL (nl 5.3-22.5), fasting blood glucose 83 mg/dL(nl 70-99), fasting insulin 6.9 mIU/L( nl 0-24.9), proinsulin 16.9 pmol/L ( nl <=18.8 pmol/L), c-peptide 1.39 ng/mL( nl 0.81-3.85), beta-OH butyrate 0.072 mmol/L( nl 0.020-0.270). Islet cell Ab was normal. Gastric emptying study was negative. Although the dose of bromocriptine was reduced due to HYPO, it continued. He was advised to decrease intake of CARBS, eat small, high protein and fat meals with frequent snacks. On subsequent visits, he reported less hypoglycemic episodes with improved energy level and general well-being, which was confirmed by CGMS. Discussion: Although a wide range of diseases can cause HYPO in nondiabetic patients, differences in characteristics between non-diabetic HYPO and diabetic HYPO have not been well studied. Common underlying diseases associated with HYPO include malignancies, cerebrovascular diseases, infection, major organ failure, and alcohol-related disorders. In addition, comorbidities linked with HYPO include sepsis, kidney diseases, and alcohol dependence, pneumonia, liver diseases and insulin abuse. Malnutrition, alcohol, infection, and post gastrectomy are the leading causes of nondiabetic hypoglycemia. In addition, methimazole use has been associated with insulin autoimmune syndrome resulting in HYPO due to interaction of sulfhydryl group with disulfide bond in the insulin molecule Conclusion: Clinicians should be aware of the potential for hypoglycemia in non-diabetic patients, due to other etiologies, which can also result in severe and possibly life-threatening sequelae. An in-depth evaluation, including the use of CGMS can assist in determining underlying causes.

Analysis of functional outcomes post gastrectomy and oesophagectomy

Background: Advances in gastric and oesophageal cancer management have led to improved survivorship. Factors affecting quality of life in long-term survivors are now coming to the attention of caregivers. The causes are multifactorial and include structural changes in upper gastrointestinal tract, abnormal gastrointestinal motility, altered pH, bacterial overgrowth, and insufficient bile salt or pancreatic enzyme production. The objective of this study was to analyse the extent of this problem in a gastric and oesophageal cancer population.

The food characteristics of unpalatable meal contents and difference by operation types for post gastrectomy patients- comparison between total gastrectomy and distal gastrectomy

Rationale: This study aims to reveal the food characteristics of unpalatable meal contents for post Gastrectomy patients and difference between Total Gastrectomy (TG) and Distal Gastrectomy(DG).

Factor exploratory study about the food characteristics of the food contents for post gastrectomy patients

Factor exploratory study about the food characteristics of the food contents for post gastrectomy patients

Factores pronósticos de sobrevida alejada en cáncer gástrico. Introducción del nuevo índice N+/T

Background: The identification of survival prognostic factors for gastric cancer, allows us to create clinical guidelines. Chile has a deficit in the analysis of long-term survival prognostic factors. Aim: To assess different prognostic factors of long-term survival in gastric cancer. Determine the survival rate at 5 and 10-years post gastrectomy, and the value of a new prognostic factor of long-term survival called N+/T. Material and Method: Prospective study of the oncological database of the Clinical Hospital of the University of Chile between May 2004 and May 2012. Results: A total of 284 patients were included, 65.4% were men and the mean age was 64.5 years. Seventy-five percent were advanced gastric cancer, 72.5% of the patients required a total gastrectomy. The lymphadenectomy practiced was D2 in 85.2%, and average lymph node harvest was 30 lymph nodes. The postoperative morbidity and mortality was 17.2% and 1.7% respectively. The average global survival was 69.9 months, the 5-year survival was 56.9% and the 10-year survival was 53.4%. The N+/T index presented a statistically significant difference in the global survival of all the subgroups (p < 0.0001). The multivariate analysis showed that the significant variables were: N+/T index (p = 0.0001, OR: 1.1 [1.05-1.12]), LNR (p = 0.0001, OR: 5.8 [1.04-15.6]), age (p = 0.008, OR: 1.03 [1.00-1.06]), lymphovascular permeation (p = 0.0001, OR: 2.19 [1.49-3.23]), T classification (p = 0.03, OR: 3.4 [1.10-8.93]), N classification(p = 0.001, OR: 1.06 [1.02-1.10]), and TNM stage (p = 0.004, OR: 1.03 [1.01-1.06]). The areas under the ROC curves of the N+/T, LNR and T classification, were 0.789, 0.786 and 0.790 respectively (p = 0.96). Conclusion: The independent prognostic factors of long-term survival were N+/T index, LNR, age, lymphovascular permeation, T classification, N classification and TNM stage. Concomitantly, a new prognostic factor has been created to assess survival in gastric cancer, the N+/T index.

Amputation neuroma mimicking lymph node metastasis of remnant gastric cancer: a case report

BackgroundAmputation neuromas (ANs) are reactive hyperplasia of nerve tissues that occur after a trauma or surgery involving the peripheral nerves. Only two previous reports of ANs occurring around the stomach and post gastrectomy have been reported. We report the case of a patient with AN near the remnant stomach who underwent distal gastrectomy for gastric cancer.Case presentationA 76-year-old man underwent distal gastrectomy, D1+ lymphadenectomy, and Billroth-I reconstruction for early gastric cancer in another hospital at 63 years of age. A regular gastrointestinal endoscopic follow-up examination after gastrectomy revealed an ulcerative lesion on the lesser curvature of the remnant stomach, which was diagnosed as remnant gastric cancer based on the histopathological examination. Then, he was transferred to our hospital. An upper gastrointestinal series and endoscopy revealed an 18-mm Type 0-IIc lesion on the lesser curvature of the remnant stomach with an estimated depth within the mucosa (T1a). An abdominal contrast-enhanced computed tomography (CT) failed to detect the primary lesion; however, a slightly enhanced 13 × 10-mm nodule was detected near the lesser curvature of the remnant stomach. An endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the nodule showed no cancer cell; thus, endoscopic submucosal dissection (ESD) for the remnant gastric cancer was performed. Histopathological examination revealed noncurative resection due to T1b2 and UL (+). We planned an additional surgical resection. Before the resection, CT was performed, which had a 3-month interval with a previous CT, showing an enlargement of the nodule to 16 × 12 mm. We diagnosed the nodule as a lymph node metastasis and performed resection of the remnant stomach, D2 lymphadenectomy, splenectomy, and Roux-en-Y reconstruction. The nodule was later diagnosed as AN based on the histopathological examination. There was no residual cancer in the resected specimen.ConclusionsWe report AN mimicking lymph node metastasis near the remnant stomach of a patient with remnant gastric cancer. When nodules appear in the previous operative field, the possibility of ANs should be considered, although the incidence may be quite low.

Dumping syndrome post total gastrectomy

Dumping syndrome post total gastrectomy

239P Primary squamous cell carcinoma of the stomach (PSCCS) - A systematic review and meta-analysis

Background PSCCS is a rare entity with less than 150 cases reported in the literature. This study was undertaken to identify the demographic profile, patterns of care and survival data in this subset of stomach cancer. Methods Full length papers of all cases of PSCCS reported and published in English from 1950 to 2016 were independently searched and retrieved by the authors from PUBMED, Google Search and Cochrane Library. Results:32studieswithN=91werefoundtobeeligibleformeta-analysis.Eligibility criteria included full length papers, case series and reports, published in English language between 1950 and 2016. Only cases in which no other synchronous malignancyexceptforPSCCSwereincluded.Medianageofthecohortwas65years (Range 17 - 83). 72 (79.1%) were male and 19 (20.9%) were female. 63 (69.2%) patients wereofAsianoriginand28(30.8%)wereofnon-Asianorigin.Themaximumbulkof the tumour was noted in the fundus/cardia of the stomach (n = 28, 35.4%), followed by body, pylorus/antrum and post gastrectomy stump. 20% of the patients were found to bemetastaticupfront.9(9.9%)patientshadidentifiableriskfactorsfordevelopmentof squamous cell carcinoma like radiation or corrosive injury, gastrectomy or cyclophosphamide intake. Surgery was the soletreatment in n = 27 (33%), adjuvantor neoadjuvantchemotherapywasdeliveredinn=24(29.6%)andpalliativetreatmentin n=15(18.5%).Adjuvantorneoadjuvanttherapysignificantlyimprovedprogression freesurvival(PFS)butnotoverallsurvival(OS).Thechemotherapyregimen administered was heterogeneous and the most effective regimen could not be identified. OS ranged from 0 to 72 months with median of 12 months. 3 year OS was 43%. Only T stage was found to be a significant factor for OS in univariate analysis (p = 0.029). Conclusions PSCCS is a rare entity with limited data available on causation or management strategies. Adjuvant or neoadjuvant chemotherapy in addition to surgery improves PFS. Legal entity responsible for the study AIIMS Funding AIIMS Disclosure All authors have declared no conflicts of interest.

Gastrectomy is Associated with an Increased Risk of Pyogenic Liver Abscess: A 13-Year Nationwide Cohort Study.

Whether patients who have undergone gastrectomy are at a high risk of developing pyogenic liver abscess (PLA) remains debatable. From the inpatient claims records of Taiwan’s National Health Insurance Research Database, we identified 33 834 patients with a history of 2000–2010 and135 336 controls without a history of gastrectomy. The 2cohorts were matched by age, sex, and admission year and followed-up until the end of 2011 for estimating the risk of PLA. Overall, the incidence of PLA was 3.5-fold higher in the gastrectomy cohort than in the control cohort (21.6 vs 5.76 per 10 000 person-y). The adjusted hazard ratio (aHR) for the gastrectomy cohort obtained using the multivariate Cox proportional hazards regression model was 3.08 (95% confidence interval [CI] = 2.60–3.64). An elevated post gastrectomy PLA risk was observed in both men and women. Age-specific data revealed that the aHR for the gastrectomy cohort, compared with the control cohort, was the highest in patients younger than 50 years (aHR = 5.16, 95% CI = 2.96–9.01). An addition analysis showed that the gastrectomy cohort exhibited an elevated PLA risk regardless of whether the patients underwent total or partial gastrectomy. Patients with a history of gastrectomy exhibit a high risk of PLA.

What are the effects of abdominal drainage versus no drainage post gastrectomy in people with gastric cancer?

What are the effects of abdominal drainage versus no drainage post gastrectomy in people with gastric cancer?

Bone loss and vitamin D deficiency post gastrectomy for gastro-esophageal malignancy.

165 Background: Metabolic bone disease is a known but incompletely understood consequence of gastrectomy. Post gastrectomy osteoporosis (OP) is multifactorial. Evidence suggests that patients who undergo this surgery require long term bone health assessment and nutritional support. Methods: 30 post gastrectomy patients (2000-2008) from a single centre in Australia were evaluated re bone health post surgery and post nutritional supplementation. Exploratory analysis included: age, gender, pathology, type of surgery, 25 OH-vitamin D, calcium, parathyroid hormone (PTH), bone mineral density (BMD), vertebral XRs, urinary calcium and N telopeptides of type I collagen. Other risk factors evaluated were: smoking, corticosteroid use, alcohol intake, hyperthyroidism, menopausal status, hyperparathyroidism (hPTH), pre-existing bone disease. Results: The median age of the cohort was 67.5 (range 53-83) of whom 22 (73%) were male. Histology showed 16 (53%) gastric adenocarcinoma, 6 (20%) esophageal adenocarcinoma, 2 (7%) GISTs, 5 (17%) gastric/duodenal lymphoma and 1 other category. Similar numbers of patients underwent total (12) and partial/distal gastrectomy (12), with 6 having a subtotal gastrectomy. 22 (73%) had a Roux-en-Y or BR II reconstruction and 8 had a BRI/other. Median time from surgery to first BMD was 54.5 months (range 12-360) with median correlative calcium level 2.24 (range 1.97-2.49), median vitamin D level 43 (range 11-82) and median PTH 6.4 (range 1.8-13.8). Osteoporosis was diagnosed in 14 (47%) of patients, osteopenia in 14 and 2 (7%) patients had a normal BMD. Low vitamin D was seen in 23 (77%) patients, low calcium levels in 5 (17%) and secondary hPTH in 12 (41%). Post nutritional supplementation preliminary results showed 2/23 (9%) had a low vitamin D level, 3/11 (27%) had secondary hPTH, 5/19 (26%) had osteoporosis, 12/19 (63%) had osteopenia and 2/19 had a normal BMD. Analysis of other risk factors is to follow. Conclusions: Poor bone health and vitamin D deficiency is a clinically significant problem post gastrectomy. Patients should undergo long term nutritional and bone health surveillance in addition to their oncological follow up post resection.

Nontraumatic central fracture dislocation of the hip in a patient with chronic kidney disease and post gastrectomy.

Objective: Patients with secondary hyperparathyroidism caused by chronic kidney disease (CKD) develop secondary osteoporosis, which increases fracture risk. We report a case of insufficiency fractures complicated by secondary osteoporosis caused by chronic renal failure and gastrectomy.Patient: A 78-year-old man with a medical history of nephrotic syndrome and gastric cancer experienced an occult intertrochanteric fracture of his left femur after falling.Results: Ten days after the first fracture, the patient was treated with hemodialysis for acute uremic symptoms. Eight weeks after this fracture, he sustained a right insufficiency acetabular fracture and was treated with total hip arthroplasty (THA).Conclusion: For patients with CKD, effective fracture prevention is difficult. THA with reconstruction of the acetabulum was an effective therapy in a patient with nontraumatic central fracture dislocation of the hip.

Assessment of Post-operative Pain and the Activities that Increases Pain among Patients Undergoing Gastrectomy

Pain is one of the most common experiences and stressors in patients undergoing G.I. Surgeries. Patients undergoing gastrectomy may experience frequent and moderate to severe pain postoperatively. The incidence and severity of pain and a multimodal approach (use of a combination of pain control strategies including opiods, NSAIDS, non-pharmacologic intervention) to acute post gastrectomy pain is recommended. The present study was undertaken to assess the level of pain experienced by patients after gastrectomy, to identify the post-operative activities that increases pain and to find out the association between pain score of patients and the selected variables. A descriptive research design was adopted. Setting was Hi-Tech Medical college and Hospital. Sample size was 40 and convenient sampling technique was used. Wong Bakers faces pain rating scale and a validated questionnaire was used as a tool. The maximum obtainable pain score was 19. t-tests showed that the mean pain score on the second post operative day was significantly less then that of first post operative day. Chisquare test reveals that there is significant association between different degrees of pain and the selected demographic variables.

胃がん患者と家族の調理実習を取り入れたがんサロンの実際

胃がん患者と家族の調理実習を取り入れたがんサロンの実際

Quality of life following laparoscopic distal gastrectomy with modified billroth II reconstruction.

140 Background: Laparoscopic gastrectomy has been proposed as a procedure to reduce the morbidity of gastric cancer surgery. Modified Billroth II (BII) reconstruction with a side to side loop gastrojejunostomy is technically straightforward to accomplish laparoscopically. To determine the long term morbidity of this reconstruction technique, we performed a quality of life (QOL) analysis of patients undergoing laparoscopic distal gastrectomy with modified BII reconstruction. Methods: Between June 2005 and May 2011, 64 patients underwent laparoscopic distal gastrectomy with modified BII reconstruction at City of Hope Medical Center (COH). Patients alive with no evidence of disease were recruited to participate in the QOL study. The study was approved by the Institutional Research Board of COH. Research subjects completed the EORTC QOL-STO22 instrument which queried patients for post gastrectomy symptoms. Comparison between groups was done using the Student-t test. Results: 33 of 64 patients met the criteria for participation in our QOL study. Of these, 23 patients consented to participate and completed the EORTC QOL-STO22 instrument. Overall, 81% categorized symptoms as occurring “not-at-all” or “a-little” while 19% reported symptoms occurring “quite-a-bit” or “very-much”. Since symptoms could be worse in patients with small gastric pouches, we divided our cohort into two groups, one having at least 70% of the stomach resected (12 patients) and the other having less than 70% of the stomach resected (11 patients). The two groups were compared with respect to symptoms. There was no difference between the groups with respect to dysphasia (p=0.80), pain (p=0.98), reflux (p=0.93), and eating restriction (p=0.33). Overall 78% of patients with a small gastric pouch and 83% of patients with a larger gastric pouch reported these symptoms as occurring “not-at-all” or “a-little”. Conclusions: Laparoscopic distal gastrectomy with modified BII reconstruction resulted in an acceptable morbidity rate with few patients experiencing severe symptoms. Gastric pouch size did not predict symptoms and most patients with a small gastric pouch report excellent QOL.

Large aortic aneurysm mimicking a cardiac tumor

IntroductionExtrinsic left atrial compression caused by a displaced, crooked descending thoracic aorta is rare. This anomaly may mimic primary cardiac tumors or metastatic neoplasms from the first look.Case presentationWe reported a 78-year-old woman presented to our emergency room with back pain, increased exercise intolerance and intermittent angina. She also had one syncopal event 1 month ago and gastric cancer post gastrectomy history. Subsequent chest plain film showed no mediastinum widening.Two-dimensional echocardiography was performed and revealed a heterogeneous mass as large as 2.3 × 2.4 cm occupying the left atrium (LA). Three-dimensional echocardiography vividly demonstrated that LA was constrained between the aortic valve (AV) and a luminal structure with pulsatile character suggestive of the aorta.ConclusionsWe successfully demonstrated the detailed structure and location of an anomalous descending aorta on the oblique imaging plane of RT-3DE, which may not be readily available by traditional 2D method.