Previous Gastrectomy Research Articles

Second gastric cancer after curative endoscopic resection of differentiated-type early gastric cancer: post-hoc analysis of a single-arm confirmatory trial

Endoscopic resection (ER) for early gastric cancer (EGC) can preserve the stomach; however, the remaining stomach can develop second gastric cancer. Few reports have prospectively investigated the incidence and treatment outcomes of second gastric cancer. This post-hoc analysis used the dataset of the single-arm confirmatory trial, JCOG0607. The key inclusion criteria for JCOG0607 were solitary differentiated-type EGC and no previous gastrectomy or endoscopic treatment for EGC. Three hundred seventeen patients who underwent curative ER were included in this study. Surveillance endoscopy was performed 1 to 3 months after the initial ER and subsequently annually for at least 5 years. A lesion detected≤1 year and >1 year after the initial ER was defined as overlooked gastric cancer (OGC) and metachronous gastric cancer (MGC), respectively. During a median follow-up period of 6.0 years (interquartile range, 5.1-7.0), 30 OGCs and 61 MGCs were detected in 24 and 48 patients, respectively. The cumulative incidence of OGC at 1 year and MGC at 5 years was 7.6% and 12.7%, respectively. ER and gastrectomy were performed in 85 lesions and 6 lesions, respectively. Pathologic evaluation showed 78 mucosal cancers, 12 submucosal cancers, and 1 advanced cancer. Eventually, 28 OGCs and 52 MGCs fulfilled the pathologic criteria for curative ER. Our study was the first to reveal the actual incidence of second gastric cancer after curative ER for differentiated-type gastric cancer. Most lesions could be treated with ER. Continuous endoscopic surveillance after curative ER is important to detect second gastric cancer.

Reflux, Barrett's Esophagus, and Esophageal Adenocarcinoma After Bariatric Surgery.

We present the case of a patient who developed esophageal adenocarcinoma after a previous laparoscopic sleeve gastrectomy. Bariatric surgery has emerged as the most effective treatment option for weight loss and obesity-related diseases; however, sleeve gastrectomy promotes gastroesophageal reflux and leads to Barrett's esophagus in a substantial portion of patients. The natural history of Barrett's esophagus in these patients is unknown, and active surveillance is recommended until the incidence of dysplasia and adenocarcinoma in this population is clarified. Management options for these patients include conversion to Roux-en-Y gastric bypass. Although esophagectomy in patients who have previously undergone sleeve gastrectomy may require an alternative conduit, the remnant stomach can be used in carefully selected patients. Here, we review the different weight loss procedures, their effect on gastroesophageal reflux disease and Barrett's esophagus, and the treatment options for patients with esophageal cancer after sleeve gastrectomy. We report the use of preoperative coil embolization as a means of vascular preconditioning before successful use of a gastric conduit.

Delayed Splenic Abscess Post Splenic Arterial Embolization for Trauma in a Patient with Previous Sleeve Gastrectomy

In this report, we present a rare case of delayed splenic abscess formation with upper pole necrosis following proximal splenic artery embolization in a patient with impaired splenic collateral blood supply, having previously undergone sleeve gastrectomy surgery for weight loss. Consent was obtained from the patient for the writing of this case report.

Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass. A case report and literature review.

Introduction and importanceOne of the most performed bariatric procedures, Laparoscopic sleeve gastrectomy (LSG) can be utilized not only as a primary bariatric procedure to achieve weight loss but also as a staged procedure, as it attains durable weight loss on long term follow up with remission of obesity-related comorbidities. There are several complications associated with LSG in the short and long terms, including hemorrhage, gastric leakage, and gastroesophageal reflux disease (GERD), yet gastric volvulus after sleeve gastrectomy is a rare entity.Case presentation and clinical discussionWe present a morbid obese female patient 32 years old -with no known medical comorbidity- presented to our bariatric outpatient clinic after laparoscopic sleeve gastrectomy with a chronic progressive history of vomiting, regurgitation, and heartburn of three months which started once/week then progress to 3 times/week duration. After a normal abdominal x-ray, Pelvi-abdominal ultrasound showed mild colonic gaseous distension. The CT virtual gastroscopy with 3D reconstruction revealed significant mid-body kinking with a wavy appearance. A decision was made on a multi-disciplinary approach to do a diagnostic laparoscopy for the patient with a revision of the previous sleeve gastrectomy. Upon entering the intra-abdominal there were extensive adhesions between the sleeved stomach, liver, and pancreas. Intra-operative upper endoscopy was done, and the scope didn't pass at the mid-portion of the sleeved stomach. Conversion to Roux-en-Y gastric bypass had been done with successful results.ConclusionGastric volvulus after sleeve gastrectomy is a rare entity presenting vague symptoms and signs and requires a high index of suspicion from the physicians for the proper diagnosis.

Three-Tier Prognostic Index in Young Adults With Advanced Gastric Cancer.

PurposeTo characterize clinical features and identify baseline prognostic factors for survival in young adults with advanced gastric cancer (YAAGC).Materials and MethodsA total of 220 young inpatients (age less than or equal to 40 years) with an initial diagnosis of advanced gastric cancer were retrospectively enrolled in this study.ResultsOf a consecutive cohort of 220 patients with YAAGC, the median overall survival (OS) time was 16.3 months. One-year survival rate was 43.6% (95% CI: 36.5 to 50.7). In this cohort, a female (71.4%, n = 157) predominance and a number of patients with poorly differentiated tumors (95.9%, n = 211) were observed. In the univariate analysis, OS was significantly associated with neutrophil–lymphocyte ratio (NLR) (≥3.12), hypoproteinemia (<40 g/L), presence of peritoneal or bone metastases, and previous gastrectomy of primary tumor or radical gastrectomy. In multivariate Cox regression analysis, hypoproteinemia [hazard ratio (HR) 1.522, 95% CI 1.085 to 2.137, p = 0.015] and high NLR level (HR 1.446, 95% CI 1.022 to 2.047, p = 0.021) were two independent poor prognostic factors, while previous radical gastrectomy was associated with a favorable OS (HR 0.345, 95% CI 0.205 to 0.583, p = 0.000). A three-tier prognostic index was constructed dividing patients into good-, intermediate-, or poor-risk groups. Median OS for good-, intermediate-, and poor-risk groups was 36.43, 17.87, and 11.27 months, respectively.ConclusionsThree prognostic factors were identified, and a three-tier prognostic index was devised. The reported prognostic index may aid clinical decision-making, patient risk stratification, and planning of future clinical studies on YAAGC.

Endoscopic retrograde cholangiopancreatography using short‐type double‐balloon enteroscope: Experience in Hong Kong

To illustrate the efficacy and safety profile of double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using a short enteroscope in patients with surgically altered anatomy. A retrospective study was performed to review the endoscopic outcomes of patients undergoing DBE-assisted ERCP for biliary diseases in Tuen Mun and Pok Oi hospitals in Hong Kong SAR, China from December 2015 to December 2020. Altogether 46 DBE-assisted ERCP procedures were performed in 37 patients. The enteroscopic success rate, defined as reaching the papilla or bilioenteric anastomosis, was 95.7% (95% confidence interval [CI] 85.2%-99.5%), which was significantly lower in patients with intact stomach than in those who had a previous gastrectomy (67% vs 100%, P=0.014). The diagnostic ERCP success rate, defined as performance in an informative cholangiogram, was 84.1% (95% CI 69.9%-93.4%) in cases where it was attempted. Intended biliary therapeutic interventions were successfully performed in 76.1% (95% CI 61.2%-87.4%) of all procedures. Adverse events were reported in six (13.0%) procedures (95% CI 4.9%-26.3%), including the micro-perforation of the intestine in two (4.3%) patients with prior Roux-en-Y gastrectomy, three (6.5%) of acute cholangitis and one (2.2%) of acute pancreatitis. All adverse events were managed successfully using conservative methods except in one case of micro-perforation, which required a laparotomy. DBE-assisted ERCP using a short enteroscope is a promising technique for managing biliary diseases in patients with surgically altered anatomy. It must be performed to avoid perforation, particularly in patients with a Roux-en-Y reconstruction.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience.

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8days (IQR 7-11) and 12months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

MO5-3 Nivolumab monotherapy in 3rd-line treatment for HER2 positive or negative advanced gastric cancer

Trastuzumab deruxtecan (DS-8201) showed clinical benefit among HER2 positive (H+) advanced gastric cancer (AGC) patients who received at least two previous therapies. Subgroup analysis of ATTRACTION-2 trial showed that nivolumab was efficacious regardless of prior Trastuzumab use. Little is known about proper use of nivolumab, trifluridine/tipiracil, and DS-8201 in 3rd-line treatment. The purpose of this study is to compare nivolumab efficacy between H+ and HER2 negative (H-) AGC patients in clinical practice. We retrospectively reviewed the medical record of 38 AGC patients who received nivolumab monotherapy in 3rd-line treatment at our institution until August 2020. The baseline characteristics of H+ group (n=10)/ H- group (n=28) were as follows: median age, 71/69 years; male, 90%/68%; ECOG PS 0-1, 80%/79%; previous gastrectomy, 20%/29%; intestinal type, 60%/43%; liver meta, 50%/32%; and ascites, 40%/54%. All H+ patients had received trastuzumab. Among 6 in H+ group/ 16 in H- group who had measurable lesions, objective response rate was 33%/19%. Median progression-free survival and median overall survival were 3.5/1.8 months and 8.2/7.5 months, respectively. The frequencies of immune-related adverse events between two groups were similar (20%/14%). H+ was associated with better outcome of nivolumab monotherapy compared with H-, although this study was small sample size and single institutional retrospective analysis.

Serum Gastrin Predicts Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Patients With Abdominal Surgery: A Prospective Study.

OBJECTIVES:Small intestinal bacterial overgrowth (SIBO) might be associated with a history of abdominal surgery. We aimed to evaluate the prevalence of SIBO and to investigate serum gastrin and pepsinogen as predictors of SIBO in patients with a history of hysterectomy, gastrectomy, or cholecystectomy.METHODS:This prospective study surveyed 146 patients with a history of hysterectomy, gastrectomy, or cholecystectomy, and 30 healthy controls, who underwent a hydrogen (H2)-methane (CH4) glucose breath test (GBT) for SIBO. Serum pepsinogen I and II and gastrin levels were reviewed.RESULTS:GBT positivity (+) was significantly higher in patients with histories of abdominal surgery than that in in controls (37.6% vs 13.3%, P < 0.01). Among GBT+ patients, 36.0% (18/50), 96.2% (25/26), and 17.1% (12/70) were in the hysterectomy, gastrectomy, and cholecystectomy groups, respectively. Among the GBT subtypes, 43.6% (24/55), 10.9% (6/55), and 45.5% (25/55) of patients were in the GBT(H2)+, GBT(CH4)+, and GBT(mixed)+ groups, respectively. The gastrectomy group had significantly more GBT+ or GBT(H2)+ patients than the other surgical groups. Gastrin levels were higher in GBT(H2)+ patients and lower in GBT(CH4)+ patients than those in GBT− patients. Previous gastrectomy and elevated gastrin levels were independent predictive factors of GBT(H2)+.DISCUSSION:SIBO is not uncommon in patients with histories of abdominal surgeries, but it is more common in patients who have undergone gastrectomy. Serum gastrin level could be a serologic predictor of H2-producing SIBO. The relationship between serum gastrin and SIBO requires further research.

Short-term results of single-anastomosis gastric bypass after failed sleeve gastrectomy

Background It is recognized that sleeve gastrectomy (SG) is one of the most common bariatric procedures worldwide. It is considered a relatively safe and effective option in the treatment of morbid obesity. However, SG operations may fail in the treatment of obesity. In cases of unsuccessful SG surgery, revisional bariatric surgery may be used. One anastomosis gastric bypass (OAGB) was considered as an outstanding choice for revision surgery. Objective To assess the efficacy and safety of OAGB as a redo surgery after the failure of previous sleeve gastrectomy operation. Patients and methods This study is a retrospective cohort study, conducted in Bariatric Surgery Unit, Ain Shams University Hospital, Cairo, Egypt, from February 2018 to July 2019, with 6 months of postoperative follow-up till January 2020. We included 50 patients who underwent OAGB who were adults fit for surgery, aged between 18 and 60 years, with a history of failed SG. Results A total of 50 patients with history of failed SG underwent OAGB surgery with excess body weight loss of 14.10% at 1 month, 28.85% at 3 months, and 45.43% at 6 months. Weight loss was 7.14–32.43 kg (SD 6.14). The type 2 diabetes mellitus remission rate was 100% by 6 months, with glycated hemoglobin level of 5.88±0.77 (range, 5.4–7.2). Hypertension resolution was 40%. Overall, 100% of patients with sleep apnea improved symptomatically. No morbidity or mortality cases were reported. Conclusion OAGB operation is considered to be an effective and safe revisional surgical procedure after a failed primary SG operation.

Clinical characteristics and management of Petersen hernia after gastrectomy in patients with gastric cancer

Objective: Petersen hernia is a rare but severe complication after gastrectomy, which has been reported by very few studies. This study is dedicated to summarize the clinical characteristics and management of Petersen hernia after gastrectomy in patients with gastric cancer in order to provide reference to clinical practice. Methods: A descriptive case-control study was carried out. All the qualified patients were screened from the database of digestive malignancies in Nanjing Drum Tower Hospital. The inclusion criteria were as follows: Petersen hernia confirmed during operation; previous gastrectomy history due to gastric cancer; complete clinical data. The clinical manifestation, perioperative data and follow-up outcome were summarized. Results: A total of 12 qualified patients were included. They were all male with a mean age of (65.3±8.5) years old, and whose clinical presentation had last for (6~143) hours (median: 21 hours). Common complaints included abdominal pain and bloating. All the patients were admitted to the emergency department. Preoperative CT showed dilatation and effusion of small intestine. Other imaging manifestations included whirlpool sign, target sign, mesenteric retraction or congestion and edema, abdominal and pelvic effusion, etc. Hematological examination showed white blood cell count, ratio of neutrophils, procalcitonin and C-reactive protein were higher than the normal range. The median interval to previous gastrectomy is 20.5 (0.5-55.0) months. The previous gastrectomy of 12 cases included 2 cases of laparoscopic surgery and 10 of laparotomies. Ten cases underwent emergency surgery immediately, and 2 cases underwent surgery after ineffective conservative treatment. Six cases received small bowel restoration without bowel resection, and the other 6 cases received small bowel resection with a mean length of 76 (11~300) cm. Six cases were transferred into ICU with a stay of (2.5±0.8) days. One case deceased at postoperative day 2, due to subtotal small bowel resection, and the other 11 cases survived without grade III or above complication according to Clavien-Dindo classification. The overall postoperative hospitalization was (9.2±3.6) days. During the postoperative follow-up, no acute gastrointestinal symptoms or acute abdomen recurred. Conclusions: Petersen hernia is more common in male, whose onset and progress are rapid and emergent, and prognosis is poor.

Postgastrectomy gastric cancer patients are at high risk for colorectal neoplasia: a case control study

Background/AimsSeveral studies have shown that colorectal neoplasms (CRN) including colorectal cancer (CRC) may be prevalent in patients with gastric cancer. However, in most of these studies, colonoscopy to investigate the prevalence of CRN was performed prior to surgery. We aimed to investigate whether CRN was more prevalent in postgastrectomy gastric cancer patients than in healthy individuals.MethodsWe reviewed the medical records of those patients within a cohort of gastric cancer patients with gastrectomy who underwent colonoscopy between 2016 and 2017. Controls age- and sex-matched with gastric cancer patients at a 2:1 ratio were identified among those who underwent colonoscopy at a health-promotion center. The frequencies of CRN, advanced CRN (ACRN), and CRC among patients with gastrectomy were compared with those in the control subjects. A total of 744 individuals (gastric cancer, 248; control, 496) were included.ResultsThe rates of CRN and ACRN in the gastric cancer group were higher than those in the healthy individuals (CRN, 47.6% vs. 34.7%, P<0.001; ACRN, 16.9% vs. 10.9%, P=0.020). The rate of CRC was comparable between the 2 groups (2.0% vs. 0.6%, P=0.125). Multivariate analysis identified previous gastrectomy for gastric cancer and male sex as significant risk factors for (A)CRN.ConclusionsCRN and ACRN were more prevalent in patients who underwent surgery for gastric cancer than in the control group. Regular surveillance colonoscopy at appropriate intervals is indicated after gastrectomy.

Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks

Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and2019. Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.

S1382 The Great Imitator: A Case of Early Onset Pancreatic Cancer

INTRODUCTION: Pancreatic cancer (PC) is one of the deadliest malignancies, and represents the fourth leading cause of cancer death in the United States. According to the Surveillance, Epidemiology, and End Results (SEER) registry, fewer than 2 percent of patients with PC are under the age of 45. Those who are diagnosed with PC at a younger age consistently show better outcomes, including overall, progression-free and disease-free survivals. CASE DESCRIPTION/METHODS: We present a case of a 35-year-old woman with past medical history of cholelithiasis status post endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of choledocholiths followed by cholecystectomy at the age of 20 and morbid obesity status post laparoscopic gastric sleeve at the age of 30 who was referred for ERCP with extraction of choledocholiths. She underwent a magnetic resonance imaging (MRI) which revealed a 3.1 × 2.8 cm mildly heterogeneously enhancing pancreas head mass (Figure 1A) associated with marked upstream dilation of the biliary tree (Figure 1B). Endoscopic ultrasonography (EUS) revealed a 23.7 × 22.1 mm hypoechoic heterogeneous pancreas head mass with ill-defined borders. Fine needle biopsy (FNB) was performed (Figure 2A) with pathology revealing adenocarcinoma (Figure 2B). Due to external compression of pancreas mass on duodenum, major ampulla was not visualized, and ERCP was performed by rendezvous technique in conjunction with interventional radiology (Figure 3A). A transpapillary fully covered self-expanding metal stent (FC-SEMS) was successfully deployed resulting in biliary decompression (Figure 3B). As there was no imaging evidence of metastatic disease, patient was referred for resection with curative intent after neoadjuvant chemotherapy administration. DISCUSSION: PC prevalence in patients under the age of 50 remains rare. Certain risk factors for early onset are similar to those for late onset PC. These include alcohol use, tobacco use, chronic pancreatitis, diabetes mellitus, obesity and previous cholecystectomy or gastrectomy. In early onset PC, special attention should be paid to molecular genetics. The typical oncogenes, such as KRAS and c-Myc, and tumor suppressor genes, such as TP53, CDKN2a and SMAD4, still play a role, however, special attention should be paid to BRCA 1 and BRCA 2 germline mutations, as these patients show a particularly early disease onset. Surgical resection is the only curative therapeutic approach, and early detection is essential to ensure resectability.Figure 1.: (A) MRI axial image displaying pancreatic head mass; (B) MRCP coronal image displaying biliary ductal dilation upstream from pancreatic mass.Figure 2.: (A) EUS image with FNB of pancreatic head mass; (B) pathology slide displaying high magnification image of pancreatic adenocarcinoma.Figure 3.: (A) Biliary access achieved by rendezvous technique with interventional radiology; (B) Transpapillary fully covered self expanding metal stent successfully deployed.

Fetal fractional limb volumes in pregnancies following bariatric surgery.

Obesity rates have reached an epidemic level and bariatric surgery is the most effective method of sustainable weight loss. Pregnancy following bariatric surgery is associated with an increased prevalence of small babies. The objective of the study is to compare the fetal fat distribution, as assessed by fractional arm and thigh volume using three-dimensional ultrasonography, in pregnancies following maternal bariatric surgery with those without such history. This is a prospective, longitudinal, observational study conducted in a Maternity Unit in the UK. The study included 189 pregnant women; 63 with previous bariatric surgery [27 restrictive (13 with gastric band, 14 with sleeve gastrectomy) and 36 malabsorptive procedures] and 126 with no previous surgery but similar maternal booking body mass index. Fetal arm and thigh volume were obtained at 30-33 and 35-37weeks' gestation and fractional limb volumes were calculated using a commercially available software. Women underwent a 75g, 2h oral glucose tolerance test at 28-31weeks of gestation. Overall, adjusted fetal arm and thigh volume were smaller in the post-bariatric, compared to the no surgery, group and this was more marked in women who had undergone a previous sleeve gastrectomy (P<.001 and P=.002, respectively) or a malabsorptive procedure (P<.001 for both). There was a strong positive correlation between maternal fasting/post-prandial (2h) glucose levels, at the time of the oral glucose tolerance test, and arm and thigh volume at both 30-33 and 35-37weeks (P<.01 for all). The study has demonstrated that in the third trimester of pregnancy, fetuses of women with previous bariatric surgery have smaller fractional limb volumes, therefore less soft tissue, compared to fetuses of women without such surgery and this may be related to the lower maternal glucose levels seen in the former pregnancies.

Surgical Outcome of Laparoscopic Cholecystectomy in Patients With a History of Gastrectomy.

Although laparoscopic cholecystectomy (LC) has been applied to patients with a history of abdominal surgery, we lack data on the surgical outcome of LC in patients with a history of gastrectomy. Here, we assessed the outcomes of LC and investigated predictive factors for conversion from laparoscopic to open surgery in patients with a gastrectomy history. We retrospectively compared the surgical outcomes of LC between patients with and without a history of gastrectomy. We performed multivariate regressions to identify independent predictive factors for open conversion during an LC. Among 2235 patients who underwent LCs, 39 (1.7%) had undergone a previous gastrectomy (29 men, 10 women; mean age, 72 y; 34 with distal gastrectomy and 5 with total gastrectomy). The operation time, intraoperative bleeding, postoperative hospital stays, and conversion rate were significantly worse in patients with, compared with those without the history of gastrectomy. Conversion during an LC in the cases with a history of gastrectomy was significantly correlated with age and the type of gastrectomy. These results suggested that LC in patients with a history of gastrectomy exhibited worse outcomes in terms of operation time, intraoperative bleeding, postoperative hospital stay, and conversion rate than those without it. Furthermore, it was also implied that age and the type of gastrectomy were significant predictive factors for conversion during an LC in patients with a history of gastrectomy.

Гастроеюнодуоденостомия в профилактике и лечении несостоятельности культи двенадцатиперстной кишки после резекции желудка по поводу язвенной болезни

Гастроеюнодуоденостомия в профилактике и лечении несостоятельности культи двенадцатиперстной кишки после резекции желудка по поводу язвенной болезни

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer.

BackgroundPatients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux‐en‐Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one‐stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer.MethodsThis retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end‐point was complete clearance of the CBD stones.ResultsOf the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102‐144 minutes), and the mean blood loss was 12.4 mL (range, 1‐50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3‐7 days).ConclusionOne‐stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Lymph Node Metastasis and Recurrences from Esophageal Squamous Cell Carcinoma in Patients with Previous Gastrectomy.

Esophageal cancer patients sometimes have a history of previous gastrectomy. To determine whether we should resect or preserve the remnant stomach, we need to understand the frequency and sites of abdominal lymph node (LN) metastasis from esophageal cancer after gastrectomy. In 46 patients with thoracic esophageal squamous cell carcinoma (ESCC) who had a history of previous gastrectomy due to gastric cancer (n = 20) or benign disease (n = 26), the frequency and sites of any LN metastasis including LN metastasis at surgery and LN recurrence were investigated. The factors associated with abdominal LN metastasis were also examined. The incidence of metastasis to cervical, mediastinal, and abdominal LNs at surgery was 10.8%, 30.4%, and 30.4%, respectively. The incidence of abdominal LN recurrence was 6.5%. Of 46 patients, 16 patients (34.8%) had any abdominal LN metastasis, including abdominal LN metastasis at surgery or abdominal LN recurrence. There was no significant difference in the incidence of any abdominal LN metastasis between the gastric cancer group and the benign disease group (25.0% vs. 42.3%, p = 0.222). Clinically, nodal status was identified as the only independent factor associated with the occurrence of any abdominal LN metastasis, although neither tumor location nor the reason for gastrectomy was. The present study showed that the incidence of abdominal LN metastasis from ESCC after gastrectomy was not necessarily low, regardless of the tumor location and the reason for previous gastrectomy. This result suggests that gastrectomy should not be omitted easily in ESCC patients after previous gastrectomy.

Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections

BackgroundThe rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. MethodsWe performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. ResultsGram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19–25.23; P = 0.029). ConclusionsPrevious gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.