Remnant Stomach Research Articles

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUNDThree-dimensional (3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach (CRS), but its clinical efficacy remains controversial.AIMTo compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy (3DLAG) with open gastrectomy (OG) for CRS.METHODSThe clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up, we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival (OS) rates were compared between the two groups.RESULTSAmong 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score, initial disease state (benign or malignant), primary surgical anastomosis method, interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss (188.33 ± 191.35 mL vs 305.83 ± 303.66 mL; P = 0.045) and smaller incision (10.86 ± 3.18 cm vs 20.06 ± 5.17 cm; P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG (14.0 ± 7.17 vs 10.73 ± 6.82; P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups (1.56 ± 2.84 vs 2.35 ± 5.28; P = 0.413). The complication rate (8.3% vs 20.8%; P = 0.207) and intensive care unit admission rate (5.6% vs 14.5%; P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval (CI): 72.4%-95.6%] and 73.3% (95%CI: 60.0%-89.5%) respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3% (95%CI: 76.4%-99.8%) and 75.6% (95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups (P = 0.68).CONCLUSIONCompared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.

EP-664 Remnant of stomach strangulation post Roux-en-y gastric bypass and hiatal hernia repair for obesity

Abstract Introduction and Background Herniation of the remnant of the stomach post Roux-en-gastric bypass and hiatal hernia repair is a very rare complication that require high index of suspicion to diagnose and immediate surgical intervention. In the literature, there were reported cases of herniation of gastric pouch and Roux limb but not the remnant of the stomach hence we report this unusual case. Case report A 66-year-old lady was admitted with dysphagia, vomiting, epigastric and retrosternal chest pain. She has had laparoscopic Roux-en-y gastric bypass and hiatal hernia repair 8 years before this admission complicated with recurrence of the hiatal hernia which was repaired one year prior to this presentation. CT scan of the chest and abdomen showed herniation of both the neo-stomach and the gastric remnant up in the posterior mediastinum through the hiatus. Patient consented for repair on the next day however her condition deteriorated over night and was taken to theatre and underwent emergency laparoscopic converted to open resection of strangulated ischemic remnant of stomach and preservation of the gastric pouch and the Roux limb. Conclusion This a very rare and uncommon event following a Roux-en-y gastric bypass and hiatal hernia repair, a prompt diagnosis and early surgical intervention is imperative to avoid catastrophic complications.

Risk factors associating with delayed gastric emptying after laparoscopic distal gastrectomy.

The aim of this study was to investigate the incidence of delayed gastric emptying among the patients receiving laparoscopic distal gastrectomy, and to explore their clinical features and risk factors. Clinical data were collected for 223 patients who underwent laparoscopic distal gastrectomy for gastric cancer. We retrospectively evaluated the clinicopathological features and analyzed the incidence of delayed gastric emptying among 223 patients. Delayed gastric emptying was diagnosed by patient's symptoms and the plane radiograph with an air fluid level and dilation of the remnant stomach. Delayed gastric emptying was found in five (2.2%) of the 223 patients. By univariate logistic regression analysis, greater American Society of Anesthesiologists Physical Status (ASA-PS) and older age were significantly related to occurrence of delayed gastric emptying. By multivariate logistic regression analysis, older age was independently significantly related to incident delayed gastric emptying. The area under the curve (AUC) ((95% CI) of the receiver operating characteristic (ROC) was 0.842 (0.561-0.957). The best cutoff for discriminating patients with and without delayed gastric emptying was 80 years (sensitivity 80% and specificity 83%). Our study found the occurrence of delayed gastric emptying is possibly correlated with age. Therefore, careful perioperative observation in elderly patients may possibly be important for possible development of delayed gastric emptying after laparoscopic distal gastrectomy.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy

PurposeThis study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively.MethodsWe compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5).ResultsPostoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups.ConclusionsL-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

One anastomosis gastric bypass with fundoplication of remnant stomach for weight regain prevention: Case report.

IntroductionWeight regain is a serious issue after bariatric surgery. Using banding for one anastomotic gastric bypass prevents weight regain, but carries the risk of band erosion. The combination of bariatric procedures and fundoplication for patients without hiatal hernia probably prevents weight regain. However, no studies are demonstrating this.Presentation of caseA 38-year-old woman who underwent laparoscopic one anastomosis gastric bypass with fundoplication of remnant stomach maintained a stable body weight after 5 years.DiscussionOwing to the complications associated with the conventional methods, the combination treatment has several advantages such as prevention leak of suture line in the gastric pouch prevention.ConclusionThe combination treatment could successfully prevent weight regain and thus, will be helpful in the better management of obesity.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition

BackgroundThis retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction.MethodsSixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes.ResultsBefore matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030).ConclusionsSubtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

A184 Inconspicuous Intussusception after a Gastric Bypass in the Remnant Stomach: Case report and Review of the Literature

A184 Inconspicuous Intussusception after a Gastric Bypass in the Remnant Stomach: Case report and Review of the Literature

Laparoscopic Esophagogastric Anastomosis With Stapled Pseudo-Fornix for Reflux Esophagitis Prevention After Proximal Gastrectomy.

Laparoscopic esophagogastric anastomosis is not commonly performed after proximal gastrectomy (PG) because of its technical complexity and the lack of a gold standard for reconstruction. We describe a simple and convenient technique of laparoscopic esophagogastrostomy with stapled pseudo-fornix for reflux esophagitis (RE) prevention after PG.Laparoscopic PG (LPG) was performed in four patients with gastric cancer in the upper third of the stomach, and the remnant stomach was prepared for reconstruction. After making a small hole on the anterior wall of the remnant stomach 45 mm distal to the proximal stump and on the dorsal side of the esophageal stump, a 45 mm no-knife linear stapler was applied. To create a "pseudo-fornix," a common lumen was made by cutting the center of the four staple rows at a length of 15 mm. The entry hole was closed using the laparoscopic hand-sewn suturing technique.The mean operation time was 240 min, with an estimated blood loss of <10 ml. No intraoperative complications or conversion to open surgery were observed. One patient developed stenosis of the esophagogastrostomy successfully treated by endoscopic balloon dilatation. Endoscopic surveillance three months after surgery revealed no incidence of RE in any of the patients.Laparoscopic esophagogastric anastomosis with stapled pseudo-fornix is convenient and beneficial in preventing RE after PG and should be considered the treatment of choice for reconstruction after LPG in selected patients with proximal gastric cancer.

Gastric Adenocarcinoma of the Remnant Stomach Presenting With a Cystic Intra-abdominal Mass 11 Years After Roux-en-Y Gastric Bypass.

CASE REPORT Morbid obesity defined as a body mass index of ≥ 40 kg/m2 is associated with increased morbidity and all-cause mortality.1 Roux-en-Y gastric bypass (RYGB) is the desired surgical intervention because of its proven benefits.1,2 Morbid obesity is associated with increased risk of gastric cancer; however, the altered anatomy of the stomach after bypass is challenging for ongoing surveillance of the remnant stomach.2 To date, only 17 cases of gastric remnant malignancy after RYGB are reported.2 We present a rare case of gastric remnant adenocarcinoma 11 years after RYGB presenting with abdominal pain and weight loss due to a large intra-abdominal cystic mass abutting the gastric remnant. Abdominal computed tomography without contrast revealed a large cystic structure abutting the stomach and pancreas (Figure 1). An esophagogastroduodenoscopy was normal. An endoscopic ultrasound (EUS) revealed a single round anechoic lesion >100 mm in size in the peripancreatic and perigastric peritoneal space (Figure 2). Typical mucosal, submucosal, and muscular propria layers were noted within the wall of the cystic structure without communication to the excluded stomach (Figure 3). Fine-needle aspiration of fluid (Expect 19 Gauge Flex Needle [Boston Scientific, Marlborough, MA]) demonstrated 750 mL of brown fluid with unremarkable cytology and normal lipase and amylase levels. The carcinoembryonic antigen (CEA) level in the cystic fluid was markedly elevated at 2,358 ng/mL when compared with serum CEA of 76.6 ng/mL.Figure 1.: Axial images of the abdomen and pelvis show the cystic dilation.Figure 2.: The cystic structure seen before fine-needle aspiration (FNA) (thick arrow).Figure 3.: Endoscopic ultrasound (EUS) images revealing the wall layers of the cystic structure (thick arrow) is seen after cyst fluid fine-needle aspiration (FNA), which demonstrates that it is not a cyst but a gastrointestinal structure.A second EUS performed because of recurrent abdominal distension showed a persistent cystic structure. Injection of contrast within the cystic structure demonstrated communication between the cyst and the excluded stomach. Fine-needle biopsy (Acquire 25 Gauge Needle [Boston Scientific]) of an area of the thickened gastric wall demonstrated poorly differentiated adenocarcinoma (Figure 4).Figure 4.: The area of the excluded stomach (thick arrow) with abnormal thickening of the stomach wall was biopsied revealing adenocarcinoma.Diagnosis of gastric remnant malignancy is usually confirmed at a median of 9 years after RYGB (range is 1–22 years) with abdominal computed tomography scans.2 EUS and transgastric endoscopy may be considered as alternatives to double-balloon enteroscopy for tissue biopsy in the setting of technically difficult access of the gastric remnant.3,4 Prevention and surveillance methods including remnant gastrectomy proposed in regions with a high prevalence of gastric cancer remain controversial and not well established. More studies are needed to determine whether CEA can be considered for screening of the cancer in the excluded stomach in patients with a history of morbid obesity and RYGB.5 DISCLOSURES Author contributions: GW Khneizer and BL Bick conceived and drafted the work. N. Mahendraker designed and critically revised the work, and all authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. GW Khneizer is the article guarantor. Financial disclosure: None to report. Informed consent could not be obtained from the family of the deceased. All identifying information has been removed from this case report to protect patient privacy.

Minimum resection length to ensure a pathologically negative distal margin and the preservation of a larger remnant stomach in proximal gastrectomy for early upper gastric cancer.

In proximal gastrectomy (PG), a longer distal margin (DM) length should be maintained to obtain a pathologically negative DM. However, a shorter DM length is preferred to preserve a large remnant stomach for favorable postoperative outcomes. Evidence regarding the minimum DM length to ensure a pathologically negative DM is useful. Patients who underwent PG or total gastrectomy for cT1N0M0 gastric cancer limited to the upper third were enrolled. A new parameter, ΔDM, which corresponded to the pathological extension distal to the gross tumor boundary towards the resection stump, was evaluated. The maximum ΔDM, which is the length ensuring a pathologically negative DM, was first determined. Furthermore, the possible incidences of pathologically positive DM were calculated for each pathological type and clinical tumor (cTumor) size. Of 361 patients eligible for this study, 190 and 171 were assigned to differentiated (Dif) and undifferentiated types (Und), respectively. The maximum ΔDM was 30 and 40mm in Dif and Und, respectively. Considering a correlation between cTumor size and ΔDM, and possible incidences of pathologically positive DM, 10, 20, and 30mm were the minimal gross DM lengths in Dif when cTumor size was ≤ 15mm, > 15 and ≤ 50mm, and > 50mm, respectively. In Und, the incidences of pathologically positive DM were 0.59% and 2.3% for gross DM lengths of 30 and 20mm, respectively. The minimum DM lengths to ensure a pathologically negative DM in PG are proposed according to the pathological type of early upper gastric cancer.

Preliminary experience with double-tract reconstruction combined with π-shaped esophagojejunal anastomosis after total laparoscopic proximal gastrectomy for the treatment of adenocarcinoma of esophagogastric junction

(1) adenocarcinoma of esophagogastric junction (Seiwert type II-III) was diagnosed by endoscopy and pathological examination; (2) ability to preserve at least 1/2 of the distal stomach after R0 resection of proximal stomach was evaluated preoperatively. (1) evaluation indicated distant metastasis of tumor or invasion of other organs; (2) short abdominal esophagus or existence of diaphragmatic hiatal hernia was assessed during the operation; (3) mesentery was too short or the tension was too high; (4) existence of severe comorbidities before surgery; (5) only palliative surgery was required in preoperative evaluation; (6) poor nutritional status. operation time, intraoperative blood loss, postoperative complications, time to first flatus and time to start liquid diet, postoperative hospital stay, operation cost, etc. Continuous variables that conformed to normal distribution were presented as mean ± standard deviation, and those that did not conform to normal distribution were presented as median (Q1,Q3). Results: All the patients successfully completed TLPG with double-tract reconstruction combined with π-shaped esophagojejunal anastomosis, and postoperative pathology showed that no cancer cells were found on the upper incision margin. The operation time was (247.9±62.4) minutes, the median intraoperative blood loss was 100.0 (62.5, 100.0) ml, no intraoperative blood transfusion was required, the incision length was (4.9±1.0) cm, and the operation cost was (55.5±0.7) thousand yuan. The median time to start liquid diet was 1.0 (1.0, 2.0) days, and the mean time to flatus was (3.1±0.9) days. All the patients were discharged uneventfully. Only 1 patient developed postoperative paralytic ileus and infectious pneumonia with Clavien-Dindo classification of grade II. The patient recovered after conservative treatment. There was no surgery-related death. The postoperative hospital stay was (8.3±2.1) days. Conclusion: The double-tract reconstruction combined with π-shaped esophagojejunal anastomosis after TLPG is safe and feasible, which can minimize surgical trauma and accelerate postoperative recovery.

History and present situation of seromuscular flap anastomosis in proximal gastrectomy

With the increasing detection rate of early upper gastric cancer and adenocarcinoma of esophagogastric junction, the safety of proximal gastrectomy with clear indications has been verified, and function-preserving proximal gastrectomy has been widely used. However, proximal gastrectomy destructs the normal anatomical structure of esophagogastric junction, resulting in severe postoperative gastroesophageal reflux symptoms and seriously affecting the quality of life. Among various anti-reflux surgery methods, reconstruction of "cardiac valve" has always been the focus of relevant scholars because its similarity with the mechanism of normal anti-reflux. After years of development, evolution and optimization, the designed seromuscular flap anastomosis includes tunnel muscle flap anastomosis, Hatafuku valvuloplasty, single muscle flap anastomosis and double muscle flap anastomosis. The double muscle flap anastomosis has become a research hotspot because it shows good anti-reflux effect in clinical application. This paper reviews the history, research status and hot issues of seromuscular flap anastomosis of esophageal remnant stomach at home and abroad.

Synchronous gallbladder metastasis originating from residual gastric cancer: a case report and the review of literature

BackgroundGastric cancer rarely metastasizes to the gallbladder. Furthermore, there has never been a case report of simultaneous gallbladder metastasis from residual gastric cancer. Here, we report a case of synchronous gallbladder metastasis originating from a residual gastric cancer.Case presentationA 67-year-old man underwent a follow-up upper endoscopy 18 months after a partial gastrectomy for gastric cancer; an ulcerative lesion was found in the remnant stomach at the gastrojejunal anastomosis. A biopsy revealed gastric signet-ring cell carcinoma (SRCC). A full-body examination revealed no abnormalities other than gallstones in the gallbladder. With a diagnosis of residual gastric cancer (cT2N0M0 cStage I), the patient underwent open total gastrectomy and cholecystectomy. Macroscopic findings of the resected specimen revealed thickening of the gallbladder wall; however, no obvious neoplastic lesions were found on the mucosal surface of the gallbladder. The pathological findings showed that the SRCC had invaded the submucosa of the gastrojejunostomy site with a high degree of lymphatic invasion and lymph node metastases. SRCCs were also found in the lymphatic vessels of the gallbladder wall. These findings suggested the possibility of gallbladder metastasis through lymphatic vessels. The patient and his family members refused postoperative chemotherapy. Ten months after the operation, the patient experienced respiratory failure due to lymphangitis carcinomatosa and died.ConclusionsAt present, it is difficult to determine whether resection of the gallbladder contributes to an improved prognosis of gastric cancer patients. However, reports in such cases demonstrate that gallbladder metastasis could be a poor predictor of prognosis for gastric cancer.

Optimal Procedures for Double Tract Reconstruction After Proximal Gastrectomy Assessed by Postgastrectomy Syndrome Assessment Scale-45

BackgroundAlthough double tract reconstruction after proximal gastrectomy (PGDT) is commonly performed for proximal gastric or esophagogastric junction cancer, the impact of the procedure on postoperative quality of life (QOL) has not been clarified. We aimed to clarify the optimal PGDT procedure in terms of postoperative QOL. MethodsPostoperative QOL was analyzed in 172 patients who underwent PGDT for proximal gastric cancer and were enrolled in the PGSAS-NEXT study, a multicenter cross-sectional study in Japan (UMIN000032221), in relation to the remnant stomach size, length of interposed jejunum between the esophagojejunostomy (E-J) and jejunogastrostomy (J-G), and size of the J-G. ResultsThe remnant stomach size was approximately one-third in 13, half in 97, and two-thirds in 60 patients. Dissatisfaction scores for symptoms, diet, work, and daily life subscales were lower in patients with a larger stomach (p < 0.05). These patients also scored better in terms of weight loss (− 13.5%, − 14.0%, and − 11.2%, respectively) and amount of food ingested per meal (52%, 62%, and 66%). The length of the interposed jejunum was ≤ 10 cm in 62 and ≥ 11 cm in 97 patients. Weight loss (− 11.3% and − 13.8%) and dissatisfaction scores were better in the ≤ 10 cm group (p < 0.05). J-G size was ≤ 5 cm in 27 and ≥ 6 cm in 135 patients. The amount of food ingested (56%, 64%) and dissatisfaction scores were better in the > 6 cm group (p < 0.05). ConclusionsLarger remnant stomach, shorter length of interposed jejunum, and longer J-G might contribute to better postoperative QOL after PGDT.

Percutaneous Radiologic Gastrostomy in Patients After Partial Gastrectomy: A Retrospective Study to Assess the Technical Feasibility of Postsurgical Remnant Stomach Access.

To evaluate the technical feasibility of percutaneous radiologic gastrostomy in patients after partial gastrectomy. This retrospective study included 15 consecutive gastrectomized patients with attempted percutaneous radiologic gastrostomy at our institution between April 2014 and March 2021. When the stomach was sufficiently insufflated to distend below the left anterior subcostal margin, percutaneous radiologic gastrostomy with gastropexy was conventionally performed by the Seldinger technique. When the stomach was still highly positioned and/or overlaid by the other organs, some adjunctive maneuvers, such as hydro-displacement, intragastric balloon support, or cephalad oblique puncture or left intercostal puncture, were employed as modified gastrostomy. Ultrasonography or x-ray or computed tomography fluoroscopy was used for imaging guidance during the gastric puncture. Adequate tube placement was defined as technical success. Technical details, clinical outcomes, and complications were reviewed. One patient underwent percutaneous radiologic jejunostomy instead of gastrostomy because safe gastric access could not be ensured. Seven patients underwent conventional gastrostomy; the other seven underwent modified gastrostomy with no gastropexy. The technical success rate was 100% (7/7) in the conventional group and 85.7% (6/7) in the modified group. The stomach was punctured under x-ray or computed tomography fluoroscopy for conventional gastrostomy. In contrast, the combination of various modalities was used for modified gastrostomy except for one failed case with unintentional transhepatic access. During a median follow-up of 108days, no major complications occurred. The adequate combination of multimodal imaging guidance and technical modifications could secure radiological creation of gastrostomy for the postsurgical stomach. Level 4, Case Series.

A 3-year follow-up study of uncut Roux-en-Y reconstruction: clinical results and outcomes.

The goal of this study was to identify the clinical outcomes of uncut Roux-en-Y reconstruction in patients who underwent totally laparoscopic distal gastrectomy (TLDG) over 3-year follow-up. From January 2016 to December 2017, 269 patients who underwent TLDG were enrolled in the study and analyzed retrospectively. They were classified into two groups according to the reconstruction method: uncut Roux-en-Y reconstruction (uncut RY) (n = 154) and Billroth II with Braun anastomosis (B-II/Braun) (n = 115). Postoperative endoscopic findings (residual food, bile reflux, gastritis, and esophagitis) and nutritional status (body weight, serum hemoglobin, total protein, and albumin levels) were assessed every 6months for 3years. Residual food was less frequent in the uncut RY group in the 6th month after TLDG (p = 0.022), but there were no differences between the two groups for the rest of the study period. The incidence of bile reflux and gastritis was low in the uncut RY group during all postoperative periods (all p &lt; 0.001). In the B-II/Braun group, the frequency of reflux esophagitis was high in the 30th and 36th months after TLDG (both p &lt; 0.001), and there were no differences between the two groups during the preceding periods. No significant differences were found with respect to nutritional status, such as body weight, serum hemoglobin, total protein, and albumin levels during all postoperative periods. Three-year follow-up outcomes showed that uncut RY can effectively reduce the incidence of bile reflux and gastritis in the remnant stomach compared to B-II/Braun after TLDG.

Comparison between Roux-en-Y gastrojejunostomy and Billroth-II with Braun anastomosis following partial gastrectomy: A randomized controlled trial

Partial gastrectomy surgeries are conducted frequently due to various reasons but there is no consensus regarding the method of choice for gastrointestinal reconstruction. In this study we aimed to compare Billroth II with Braun anastomosis and Roux-en-Y gastrojejunostomy. This randomized, Single-blind clinical trial was conducted on patients presented to surgery clinic at Besat and Taleghani hospital between 2018 and 2020 who were gastrectomy candidates. Patients undergoing Billroth II reconstruction with Braun anastomosis or Roux-en-Y gastrojejunostomy were enrolled in the study. Demographics, operation durative and intraoperative blood loss, early postoperative complications, re-admission within 30 days post operation, 30-day and 90-day mortality were recorded. at an at least 3-month post-surgery period, patients were followed for late postoperative complications. If necessary, endoscopy was conducted and biopsy was taken. Analysis was performed with SPSS version 22. A total of 84 patients in two 42-patient groups were evaluated. All parameters were the same in two groups except operation duration and intraoperative bleeding (significantly higher in RY group), food residue (significantly higher in RY group) and bile in remnant stomach (significantly higher in B2B group). These two methods of reconstruction are comparable in terms of postoperative complications and mortality rates. Food residue and bile reflux are two determinants which should be kept in mind when choosing the surgery plan by surgeons.This trial was prospectively registered in the Iranian Registry of Clinical Trials with a registration ID of IRCT20130706013875N3.

En bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy based on the mesoesophageal theory.

To investigate the effectiveness and clinical significance of thoracolaparoscopic esophagectomy with mesoesophagus excision. Patients who underwent en bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy were retrospectively enrolled. Carbon nanoparticles were used in some patients to label the esophageal drainage lymph nodes. The clinical data were analyzed. En bloc mesoesophageal esophagectomy was successfully performed in 135 patients (100%). The carbon nanoparticles were used in 10 patients, among which the left gastric arterial lymph nodes were labeled in all patients and excised together with the left gastric mesentery, mesoesophagus, esophageal cancer, lymph nodes, vessels, nerves, and adipose tissues as one intact package. The mean operation time was 182.5 ± 26.4min, intraoperative blood loss 45.9 ± 17.6ml, mean number of lymph nodes dissected 20.9 ± 8.12, extubation time of drainage tubes 7.5 ± 3.8days, first oral feeding time 7.5 ± 1.8days, and postoperative hospital stay 13 ± 5.11days. Postoperatively, anastomotic leakage occurred in six patients (4.4%), anastomotic stenosis in eight (5.9%), hoarseness in seven (5.2%), and inflammation of the remnant stomach in four (3.0%), with a complication rate of 18.5%. Patients were followed up for 13-34months (median 23). Eighteen patients presented with organ metastasis. No local recurrence or death during follow-up. Based on the membrane anatomy or mesoesophagus theory, thoracolaparoscopic en bloc mesoesophageal esophagectomy is safe, with decreased blood loss, and it is necessary to resect the left gastric artery lymph nodes together with the left gastric mesentery and its contents to completely remove the cancer.

Comparison of robotic gastrectomy and laparoscopic gastrectomy for gastric cancer: a propensity score-matched analysis.

The benefits of robotic gastrectomy (RG) over laparoscopic gastrectomy (LG) remain controversial. This single-center, propensity score-matched study aimed to compare the outcomes of RG with those of LG for treating gastric cancer. We searched the prospective gastric cancer database of our institute for patients with gastric cancer who underwent RG or LG between January 2014 and December 2019, excluding patients with remnant stomach cancer and those who underwent concurrent surgery for comorbid malignancies. One-to-one propensity score matching was performed to reduce bias from confounding patient-related variables, and short- and long-term outcomes were compared between the groups. We identified 1189 patients who underwent LG (n = 979) or RG (n = 210). After propensity score matching, we selected 210 pairs of patients who underwent LG (distal gastrectomy, 138; total or proximal gastrectomy, 72) or RG (distal gastrectomy, 143; total or proximal gastrectomy, 67). RG was associated with a significantly shorter operative time (RG = 201min vs. LG = 231min, p = 0.0051), less blood loss (RG = 13mL vs. LG = 42mL, p < 0.0001), lower postoperative morbidity (RG = 1.0% vs. LG = 4.8%, p = 0.0066), and a shorter postoperative hospital stay (p = 0.0002) than LG. Drain amylase levels on postoperative Days 1 and 3 in the RG group were significantly lower than those in the LG group (p < 0.0001). RG is a safe and feasible treatment for gastric cancer, with a shorter operative time, less blood loss, and lower postoperative morbidity than LG. The application of robotics in minimally invasive gastric cancer surgery may offer an alternative to conventional surgery. Multicenter, prospective, randomized controlled trials comparing RG with conventional LG are needed to establish the feasibility and efficacy of minimally invasive gastric cancer surgery.

Evaluating gastric remnant ischemia by indocyanine green fluorescence-guided surgery after distal gastrectomy in a patient with prior Nissen fundoplication: A case report.

IntroductionRecent studies showed that intraoperative indocyanine green (ICG) fluorescence imaging-guided surgery helped evaluate organ perfusion. Whereas whether the gastric remnant can be preserved after distal gastrectomy for the cases of post-Nissen fundoplication remains unclarified. This case report demonstrated the applicability of intraoperative ICG fluorescence-guided surgery to assess the gastric remnant's blood supply after distal gastrectomy.Case presentationA 68-year-old man who previously underwent Nissen fundoplication for esophageal hiatal hernia was diagnosed with early gastric cancer in the lower body of the stomach. We performed laparoscopic distal gastrectomy to preserve the left gastroepiploic vessels considering the dissection of a part of the short gastric vessel from the previous Nissen fundoplication. After completing Billroth I reconstruction, the color of the serosal surface did not show any signs of ischemia. However, intraoperative esophagogastroduodenoscopy showed an ischemic change of the remnant stomach. In addition, ICG fluorography revealed insufficient blood supply to the gastric remnant compared with that to the pancreas and liver. Consequently, we converted to total gastrectomy to avoid necrosis in the gastric remnant.ConclusionWe performed intraoperative ICG fluorescence-guided surgery in patients with early gastric cancer after Nissen fundoplication. ICG fluorescence may be useful in preventing postoperative gastric remnant ischemia, especially in high-risk patients.