Subtotal Gastrectomy Research Articles

S3700 Role of Immunotherapy in the Treatment of Recurrent Hereditary Diffuse Gastric Cancer

Introduction: Gastric cancer is the third leading cause of cancer related deaths worldwide. Majority of cases are sporadic although 10% demonstrate familial clustering, of which 1-3% arise from inherited cancer syndromes. Hereditary diffuse gastric cancer is a rare cancer caused by CDH1 genetic mutation, inherited in an autosomal dominant fashion. Immunotherapy has been shown to increase overall response rates in gastrointestinal cancers especially in those subgroups with DNA mismatch repair-deficient or microsatellite-instable tumors. We herein, present a case of recurrent hereditary diffuse gastric cancer with good response to chemoimmunotherapy. Case Description/Methods: This is a 41-year-old asian female with past medical history of stage IIB signet ring type gastric cancer diagnosed 12 years ago, status post subtotal gastrectomy with a block transverse colectomy followed by concurrent chemoradiation, who presented with disease recurrence after 10 years, when she was treated with neoadjuvant 5-fluorouracil based chemotherapy followed by surgical resection and adjuvant chemotherapy. Her genetic screening showed CDH1 mutation, with high risk for breast and gastric cancers. She was monitored closely with regular breast magnetic resonance imaging (MRI) and esophagogastroduodenoscopy (EGD). During one of her regular endoscopy assessments recently, she was found to have erythema of her gastric mucosa which upon biopsy confirmed recurrence of her poorly differentiated adenocarcinoma, diffuse type with signet ring features. She underwent treatment with oxaliplatin based chemotherapy combined with Nivolumab for six cycles. She responded well to chemoimmunotherapy as evidenced by positron emission tomography and computed tomography (PET CT) scan and esophagogastroduodenoscopy (EGD). She is awaiting surgical resection followed by adjuvant therapy with chemotherapy either alone or in combination with immunotherapy. Discussion: Gastrectomy and chemotherapy are the mainstay treatments for hereditary diffuse gastric cancer. Nivolumab has been shown to be effective in heavily pretreated gastric cancers. The combination therapy of nivolumab plus chemotherapy achieved a clinically meaningful overall survival benefit in the first line setting in all advanced gastric adenocarcinoma. Clinical trials and research encompassing antibody treatments, such as targeted anti-PD1 antibodies, are ongoing and could offer additional treatment options in patients with advanced gastric cancer.

S3697 A Case of a Pyloric Gland Adenoma Presenting as an Intramural Mass

Introduction: Pyloric gland adenomas (PGA) are a subset of gastric adenomas with malignant potential. They are often characterized on endoscopy as an intraluminal polypoid, dome-shaped, ulcerating, or fungating mass. Due to their risk of carcinogenesis, it is important to recognize and resect lesions that are suspicious for PGAs for further pathological examination to confirm the diagnosis. Although PGAs are characterized as mucosal or submucosal lesions, this case reviews an atypical presentation of a PGA that presents intramurally in the stomach without the common features typically visualized on direct endoscopy. Case Description/Methods: A 65-year-old female with history of GERD presented with a one-year history of globus sensation described as irritation in her throat without associated weight loss, dysphagia, or odynophagia. Symptoms were refractory to proton pump inhibitors and H2 blockers. Upon initial endoscopic evaluation, a friable 3-centimeter region of localized nodular mucosa without ulceration was found on the greater curvature of the stomach and biopsied (Figure 1A). Initial pathology report noted epithelial proliferation within gastric mucosa, but malignancy was not excluded. Follow-up CT scan showed a 1.8 × 1.3 × 1.1 centimeter intramural lesion within the greater curvature at the level of the gastric fundus (Figure 1B). Upon repeat endoscopy, re-biopsy of the lesion with snare resection for more robust tissue sampling confirmed an intramucosal adenocarcinoma arising in a pyloric gland adenoma. The patient subsequently underwent a subtotal gastrectomy with Roux-en-Y gastrojejunostomy and has begun receiving adjuvant chemotherapy with folinic acid, fluorouracil and oxaliplatin (FOLFOX). Discussion: This case demonstrates the variability in presentation of PGAs while also highlighting the carcinogenic potential to evolve into an adenocarcinoma. Unlike typical PGAs that are mucosal or submucosal, this case describes an intramural PGA, which to our knowledge, has yet to be reported in the literature. Although their incidence is rare, PGAs should be considered on the differential for atypical lesions visualized on endoscopy due to their malignant potential.Figure 1.: Friable nodular ulceration on greater curvature of stomach (A), Intramural lesion within greater curvature at level of gastric fundus on CT scan (B).

S2600 Gastric Mucormycosis: A Case of a Rare Infectious Cause of Upper GI Bleeding

Introduction: Gastric mucormycosis is a rare clinical entity that mandates upper endoscopic evaluation and specific histopathologic findings for a diagnosis. Due to its non-specific clinical presentation, it poses a diagnostic challenge for providers. We present a case of gastric mucormycosis in a critically ill and immunosuppressed patient that was discovered in the setting of evaluation of upper gastrointestinal bleeding. Case Description/Methods: A 66-year-old man with a history of a kidney transplant two years prior, with a recent diagnosis of post-transplant lymphoproliferative disorder (PTLD) and who had recently undergone an initial round of R-CHOP chemotherapy four weeks prior was admitted to the hospital with altered mentation and neutropenia. His hospital course was prolonged with multiple cardiac arrests in the setting of septic shock from his profound neutropenia. He was noted to have dark blood from his nasogastric tube and a concomitant drop in his hemoglobin, for which the Gastroenterology service was consulted. He underwent urgent upper endoscopic evaluation and was found to have both significant clot in his stomach and an ulcerated fungating lesion along the greater curvature of the stomach which was biopsied. Pathology results showed fungal organisms with special GMS stain showing morphologic features consistent with mucormycosis. The Infectious Diseases service was urgently consulted and he was started on triple anti-fungal therapy with amphotericin, micafungin and posaconazole. Otolaryngology evaluated the patient due to these endoscopic findings, with laryngoscopy negative for head and neck involvement of this infection. Surgery was consulted for evaluation of subtotal gastrectomy, but he was deemed an unsuitable surgical candidate. The patient eventually succumbed to this and passed away during his hospitalization. Discussion: Gastric mucormycosis is a rare infection that often manifests in the setting of immunosuppression as seen in solid organ transplant recipients or in patients with diabetes. The most often clinical manifestation is upper gastrointestinal bleeding, and thus endoscopic evaluation is part of the work-up to exclude other diseases that could mimic its presentation. This diagnosis often results in fatal outcomes, so early recognition is critical for both medical management with anti-fungal therapy, along with surgical management given the high failure rate of medical management alone for this diagnosis.

Complication Rates in Different Gastrectomy Techniques of Enhanced Recovery after Surgery for Gastric Cancer: A Meta-analysis.

The purpose of this study was to analyse the postoperative complications of different gastrectomy methods, and provides guidance for the development of enhanced recovery after surgery (ERAS) protocols. We searched EMBASE, Web of Science, CINAHL, PubMed, MEDLINE, and the Cochrane Central Register of Controlled Trials for articles published from database inception to January 30, 2020. Statistical analysis was performed using R version 3.6.3 with single-rate meta-analysis. A total of 22 studies with 2127 patients were included. The types of postoperative complications showed that the pooled rate of nausea and vomiting was 10.22% (95% CI 4.56 to 17.48) and the pancreatic fistula was 3.58% (2.12 to 5.35) often occurred in patients who underwent laparoscopic gastrectomy (LG). After open gastrectomy (OG), postoperative urinary retention was 3.88% (0.00 to 13.17) and pancreatic fistula was 3.81% (1.78 to 6.42). The main complications of laparoscopic-assisted total gastrectomy and laparoscopic-assisted subtotal gastrectomy were pneumonia and pancreatic fistula, the rate was 3.19% (0.94 to 0.637) and 3.06% (0.11 to 8.36), respectively. In order to reduce the incidence of complications, ERAS should be revised from the aspects of rehabilitation, intraoperative application of new technology, shortening the operation time, early detection of high-risk groups, and implementation of audit. Key Words: Enhanced recovery after surgery, Gastric cancer, Postoperative complications.

Occurrence of gastric cancer after laparoscopic Roux-en-Y gastric bypass: a systematic review

Laparoscopic Roux-en-Y gastric bypass (RYGB) is an important obesity surgery. The risk of remnant gastric cancer after RYGB for obesity is gaining growing attention from bariatric surgeons and patients with obesity. This systematic review included articles from major databases internationally and domestically that specifically described the remnant gastric cancer after RYGB intervention, a total of 21 cases was subsequently analyzed. The average median time from post-operative RYGB to diagnosis of gastric cancer was 11 years (1-28 years), the duration of gastric cancer symptoms lasted 7 days to 6 years, abdominal pain is the most common (71.4%), especially in the upper abdomen (33.3%), followed by nausea and vomiting (33.3%), over-weight loss (33.3%), and abdominal bloating (28.6%), etc. Neoplasm location was reported to occur in the antrum or the pre-pyloric region (71.4%), with adenocarcinoma being the most common tumor histology observed (71.4%), tumor stage III-IV as the most diagnosed, 38.1% of tumor were deemed to be unresectable, 52.4% of the patients performed subtotal gastrectomy and lymphadenectomy. In addition, a global article investigating the occurrence of esophageal gastric cancer after RYGB in 64 cases revealed the common preoperative medical history include smoking habits (37.5%), alcohol issues (14.0%), GERD (86.0%), presence with Barret esophagus (10.9%), patients that has other malignant tumor medical history (6.3%), first-degree relatives (6.3%), or other family members with gastric esophagus cancer family history. Although the incidence of gastric cancer after RYGB is rare, the increasing prevalence of gastric cancer development is one of great concern. A rise in clinical cases of patients treated with RYGB presents a target for future studies. Risk of gastric cancer after RYGB should be evaluated and considered in high-risk cases.

Lymph node mapping in gastric cancer: a pilot study in Western patients

SummaryIn East Asia, the role of lymph node (LN) mapping in assisting surgical lymphadenectomy, which is integral to the management of gastric cancer, has been explored. We sought to evaluate its safety and utility in Western patients. Thirteen patients with nonmetastatic gastric adenocarcinoma received endoscopic, peritumoural, submucosal indocyanine green fluorescence (ICG) injections before surgery, and ICG was assessed intraoperatively using a laparoscopic detection system. All patients underwent a laparoscopic subtotal gastrectomy, and 10 of them received D2 lymphadenectomies. ICG-mapped LNs fell outside the D1 distribution in all cases, outside the D1+ distribution in 54%, and within the D2 distribution in all cases. There were no ICG-related allergies, procedural complications, or perioperative deaths. We conclude that ICG LN mapping is safe and feasible in assisting LN dissections and localizing the primary tumour in Western patients. D2 dissections should be performed in patients with advanced gastric cancer, as LNs drained outside the D1/D1+ distributions in most cases.

Giant Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors in interstitial Cajal cells of myenteric plexus of the muscularis propria are the commonest gastrointestinal mesenchymal tumors, not exclusively, appearing in the stomach. This case report documents management of a giant gastric stromal tumor of a 75 year-old female patient presented with generalized, vague, constant abdominal pain and melena, both of a week’s duration. She had early satiety with dizziness, feeling weak, and fatigue. She had a good appetite and no weight loss, hematemesis, or vomiting. She was apyrexial, with normal vital signs. The abdomen was soft, with a palpable large mass in epigastrium and central abdomen; an abdominal CT showed a heterogeneous mass lesion of antrum of stomach. Subtotal gastrectomy with roux-en-y gastrojejunostomy was performed. Histopathology showed epithelioid high grade gastrointestinal stromal tumor. The cornerstone therapy is a full operative removal of the tumor, with adjuvant therapy with selective receptor tyrosine kinase inhibitors.

Gastric lymphangioma: a case report and review of literature

BackgroundGastric lymphangioma is one of the highly rare benign tumors characterized by multilocular or unilocular lymphatic spaces. Herein, we report a case of lymphangioma in the gastric antrum.Case presentationA 77-year-old male patient who had been experiencing epigastric discomfort for a year was presented to our hospital. A gastric subepithelial lesion was diagnosed by upper endoscopy and was entirely excised via diatal subtotal gastrectomy. Endoscopic ultrasonography revealed an echoless homogenous echo pattern in the third wall layer. A lymphangioma was diagnosed by pathologic investigation of the resected specimen. The PubMed, Embase and Web of Science databases were reviewed for literature in English while using the keywords of “gastric lymphangioma” or “lymphangioma of stomach” or “gastric lymphatic cyst” or “lymphatic cyst of stomach” and the results were discussed.ConclusionGastric lymphangioma is a rarely occurring submucosal tumor that should be considered when diagnosing subepithelial lesions in the stomach.

Vitamin B12 supplementation post-gastrectomy: a service closed-loop audit at St. James's Hospital, Dublin.

BackgroundVitamin B12 (VB12) deficiency is a well-described complication post-gastrectomy. It is caused by the loss of parietal cell mass leading to megaloblastic anaemia. This closed-loop audit assesses patient understanding of and adherence with VB12 supplementation guidelines post-gastrectomy.MethodsA closed-loop audit cycle was performed. After the first cycle, an educational intervention was actioned prior to re-audit. One hundred twenty-five patients who underwent gastrectomy between 2010 and 2020 were available for study (86 total gastrectomies (TG), 39 subtotal gastrectomies (STG)). Twenty-nine patients who had not been adherent with VB12 supplementation/surveillance were eligible for re-audit.Results91.9% (79/86) of TG patients reported adherence in regular parenteral VB12 supplementation. Adherence was significantly lower for STG for checking (and/or replacing) their VB12, with only 53.8% (21/39) checking their VB12 levels. 67/125 (53.6%) of the patients stated that they knew it was important to supplement B12 post-gastrectomy. 37.8% (43/113) of participants could explain why this was important, and 14.4% (18/125) had any knowledge of the complications of VB12 deficiency. Following re-audit, 5/8 (57.5%) of TG patients who had not been adherent with VB12 supplementation in the first cycle were now adherent with VB12 supplementation following our educational intervention. 7/17 (41.2%) of the STG group had received VB12 or made arrangements to receive supplemental VB12 if it was indicated.ConclusionThis study demonstrates good adherence in those undergoing TG. Patient understanding correlates with adherence, suggesting that patient education and knowledge reinforcement may be key to adherence with VB12 supplementation. A simple educational intervention can improve adherence with VB12 supplementation in patients undergoing gastrectomy.

Abbreviated 13C-mixed triglyceride breath test for detection of pancreatic exocrine insufficiency performs equally as standard 5-hour test in patients after gastrectomy performed for gastric cancer.

Background13C-mixed triglyceride breath test (13C-MTGT) is a non-invasive test for the detection of moderate and severe pancreatic exocrine insufficiency (PEI), but it requires prolonged breath sampling. The aim of this study was to determine the diagnostic power of abbreviated 13C-MTGT in detecting PEI in patients after subtotal and total gastrectomy performed due to gastric cancer.Subjects and methodsThis cross-sectional observational study included 3 groups of subjects; healthy controls, patients with subtotal and patients with total gastrectomy. Demographic and clinical data of patients were collected. Stool samples to determine faecal elastase (Fe-1) and chymotrypsin were collected and measured by ELISA. All subjects performed 5-hour 13C-MTGT breath test. The concentration and relative content of 13C in exhaled air was measured by isotope ratio mass spectrometer (IRMS). PEI was confirmed as values of 13C-exhalation < 26.8% after 5 hours.ResultsOverall, 65 participants were included into analysis, 22 having PEI (n = 11 after subtotal and n = 11 after total gastrectomy, both performed for gastric cancer). 13C-MTGT breath test showed difference in percent of exhaled 13C between PEI and non-PEI patients already after 60 minutes (p = 0.034). Receiver operating characteristic (ROC) curve analysis showed that cut-off value of 13.74% after 150 minutes is showing equivalent diagnostic power to the longer test with sensitivity and specificity both above 90% for the exclusion of PEI in patients after subtotal and/or total gastrectomy.ConclusionsIn this study abbreviated 13C-MTGT test could be shortened from 5 to 2.5 hours without decrease in its diagnostic accuracy for detection of PEI in patients with subtotal or total gastrectomy performed for gastric cancer. This allows significant time savings in the diagnostics of PEI in this subgroup of patients.

Surgical and Survival Outcomes of Operable Gastric Cancer-Experience from a Tertiary Care Center in South India.

Gastric cancer is one of the leading cancers in Southern India. Data regarding the gastric cancers among the Indian population is sparse. Most patients in our country have locally advanced gastric cancers due to delayed presentation. In this article, we present our data regarding the presentation patterns, epidemiological demographics, surgical outcomes, and survival patterns from a tertiary care center in South India. This is a retrospective analysis of gastric cancer patients who underwent gastrectomy in our institution between January 2015 and November 2021 (n = 102). The data regarding patient characteristics, histopathology, and perioperative outcomes were analysed from medical records. The adjuvant treatment received and survival details were collected from the follow-up records and by telephonic interviews. A total of 128 patients were assessable, 102 patients underwent gastrectomy in a period of 6years. The median age of presentation was 60years and males were more commonly affected (70.6%). Most common presentation was pain abdomen followed by gastric outlet obstruction. Adenocarcinoma NOS (93%) was the most common histological type. Most of the Patients had antropyloric growths (79.4%) and subtotal gastrectomy with D2 lymphadenectomy was the most common surgery performed. Majority of the tumors were T4 tumors (55.9%) and nodal metastases were detected in 74% of the specimens. Predominant morbidity was wound infection (6.1%) followed by anastomotic leak (5.9%) with a combined overall morbidity of 16.7% and 30-day mortality of 2.9%. Seventy five (80.5%) patients were able to complete all planned 6 cycles of adjuvant chemotherapy. The median time of survival calculated by Kaplan-Meier method was 23months with 2-year and 3-year overall survival rates of 31% and 22%, respectively. Lymphovascular invasion (LVSI) and lymph nodal burden were the risk factors associated with recurrences and deaths. The patient characteristics, histological factors, and perioperative outcomes revealed most of our patients presented in locally advanced stages with poor risk histological types and increased nodal burden contributing to the lower survival in our population. Inferior survival outcomes suggest the need to explore perioperative and neoadjuvant chemotherapy options in our population.

Primary colonic melanoma: a rare entity

Gastrointestinal melanoma is usually metastatic in origin, and primary melanoma within the gastrointestinal tract is rarely reported. Colon is considered to be an extremely uncommon site for primary melanomas. Herein, we report the first case of a large primary melanoma within the transverse colon with gastric involvement. CT scan found a mass within the colon, which seemed to connect to the gastric antrum. Esophagogastroscopy showed an ulcerated lesion in the greater curvature of the stomach. Subsequent colonoscopy identified a large ulcerated lesion rendering significant stenosis of the transverse colon. Biopsy following colonoscopy indicated a diagnosis of colonic melanoma based on pathological findings, which identified submucosal malignant melanoma cells with epithelioid and spindle features. Immunohistochemical stains were positive for S-100, HMB-45, Vimentin, and Melan-A. A series of clinical and imaging examinations revealed no suspicious primary cutaneous or ocular lesions. The diagnosis of primary colonic melanoma was considered. A radical transverse colectomy with subtotal gastrectomy were conducted subsequently. Definite diagnosis of primary colonic melanoma can be established after ruling out the possibility of being a metastasis from other more common primary sites. Primary colonic melanomas are a challenge to diagnose and often need a multidisciplinary treatment approach, including surgery, BRAF-targeted therapy, and immunotherapy.

Association Between Gut Regulatory Hormones and Post-operative Weight Loss Following Gastrectomy in Patients With Gastric Cancer.

Background/AimsPost-operative weight loss in patients with gastric cancer lead to a poor quality of life and long-term survival. This study aims to evaluate the effects of gut regulatory hormones on post-operative weight loss in patients with subtotal gastrectomy for gastric cancer.MethodsThis prospective study was conducted for 12 months post-surgery in 14 controls and 13 gastrectomy patients who underwent subtotal gastrectomy for gastric cancer. Serum plasma ghrelin, glucagon-like peptide-1, gastric inhibitory peptide-1, peptide YY, insulin, and homeostatic model assessment for insulin resistance responses to a standardized test meal were recorded at multiple time points before and after gastrectomy at 4 and 12 months.ResultsThe mean weight difference between the pre-operative state and the 4-month period was significantly reduced to 6.6 kg (P = 0.032), but significant weight reduction was not observed from 4 months to 12 months. The plasma levels of glucagon-like peptide-1, gastric inhibitory peptide-1, and peptide YY were significantly increased 4 months postoperatively compared to the pre-operative state (all P = 0.035); however, pre-operative levels and relative changes over a period of 0-4 months of hormones were not correlated with body weight changes. Only the pre-operative ghrelin at peak had a negative correlation with changes in weight reduction in the 4 months after surgery (ρ = −0.8, P = 0.024).ConclusionsSignificant weight reduction was common after subtotal gastrectomy for gastric cancer with a negative correlation pre-operative plasma ghrelin levels. Incretin hormones are modestly but significantly increased after subtotal gastrectomy; however, these changes did not affect the weight changes.

Clinical application of complete laparoscopic gastrectomy with function preservation of cardia in gastric carcinoma

To investigate the feasibility and safety of total laparoscopic cardia function preserving gastrectomy for gastric carcinoma. Clinical data of 10 patients undergoing total laparoscopic cardia function preserving gastrectomy for gastric carcinoma from November 2020 to December 2021 were retrospectively collected. There were 7 males and 3 females. The mean age was (66.1±12.9) years (ranged from 38 to 86 years). All of the 10 patients were successfully performed total laparoscopic cardia function preserving gastrectomy without conversion to laparotomy. The time of digestive tract reconstruction was (24.8±3.3) min (20-30 min), and the intraoperative blood loss was (35±24) ml(20-100 ml). The time of postoperative exhaust was (2.5±0.9) days(2-3 d), the time of postoperative liquid diet was (2.25±0.87) days(2-3 d), postoperative hospital stay was (9.5±2.1) days(6-13 d). No surgical complications such as bleeding, anastomotic fistula or anastomotic stenosis occurred. Postoperative pathology showed that the proximal and distal margins of resected specimens were negative. Patients were followed up for 2 to 15 months, respectively. No death or tumor recurrence and metastasis occurred during the follow-up period. There were no symptoms of reflux after operation. Compared with total gastrectomy and proximal gastrectomy, total laparoscopic cardia function preserving gastrectomy can theoretically reduce the incidence of reflux esophagitis. We used manual suture method for digestive tract reconstruction, which can reduce the application of 2-3 stapling studs and reduce the cost of surgical materials. Compared with subtotal gastrectomy, total laparoscopic cardia function preserving gastrectomy has the advantages of more thorough lymph node dissection, with little residual gastric tissue; therefore, the blood supply is relatively better. The incidence of reflux esophagitis of total laparoscopic cardia function preserving gastrectomy for gastric cancer may was lower than total gastrectomy.

A025 Robotic Sub-total Gastrectomy for Refractory Marginal Ulcers after Gastric Bypass

A025 Robotic Sub-total Gastrectomy for Refractory Marginal Ulcers after Gastric Bypass

Nutritional Status and Related Factors in Patients with Gastric Cancer after Gastrectomy: A Cross-Sectional Study.

Patients after gastrectomy for gastric cancer are at risk of malnutrition, and poor nutritional status negatively affects patients’ clinical outcomes. Knowledge of the factors influencing patients’ nutritional status can inform interventions for improving patients’ nutrition. A cross-sectional study was conducted to describe nutritional status and related factors in gastric cancer patients after gastrectomy. A convenience sample of gastric cancer patients with gastrectomy was recruited from general surgery or oncology clinics of a medical center in northern Taiwan. Data were collected with self-reported questionnaires, including the Functional Assessment Cancer Therapy—Gastric Module version 4, the Concerns in Meal Preparation scale, the Center for Epidemiologic Studies Depression Scale, and the Mini Nutrition Assessment. One hundred and one gastric cancer patients participated in the study. There were 81 cases of subtotal gastrectomy and 20 cases of total gastrectomy. Most patients (52.5%) were malnourished or at risk. Linear regression showed that symptom severity (β = −0.43), employment status (β = 0.19), and difficulty in diet preparation (β = −0.21) were significant predictors of nutritional status. Together, these three variables explained 35.8% of the variance in patient nutritional status (F = 20.3, p < 0.001). More than 50% of our participants were malnourished or at risk for malnutrition, indicating a need for continued monitoring and support after discharge from hospitals. Special attention should be given to patients with severe symptoms, unemployment, and difficulties in diet preparation.

Clinical Efficacy of Laparoscopic Billroth II Subtotal Gastrectomy Plus Lienal Polypeptide Injection for Gastric Cancer.

Objective To evaluate the clinical efficacy of laparoscopic Billroth II subtotal gastrectomy plus lienal polypeptide injection for gastric cancer. Methods Between May 2018 and January 2021, 110 patients with gastric cancer treated in Jingzhou First People's Hospital were recruited and assigned via the random number table method to either an observation group or a control group, with 55 patients in each group. All patients received laparoscopic Billroth II subtotal gastrectomy, and the observation group additionally received lienal polypeptide injection. Outcome measures include surgical indexes, clinical efficacy, and adverse events. Results The patients in the observation group had significantly less intraoperative hemorrhage volume, smaller surgical wounds, shorter time lapse before passing gas and hospital stay, and longer operation time than those in the control group (P < 0.001). The observation group showed significantly higher efficacy than the control group (P=0.001). The observation group had a significantly lower incidence of toxic side effects and adverse events than the control group (P < 0.05). After treatment, the CD3+ and CD4+ levels were significantly elevated and the CD8+ level was decreased, with higher CD3+ and CD4+ levels and lower CD8+ levels in the observation group than in the control group (P < 0.05). Conclusion In the treatment of patients with gastric cancer, laparoscopic Billroth II subtotal gastrectomy plus lienal polypeptide injection features promising efficacy, improves the immune function of patients, effectively reduces the occurrence of toxic side effects and adverse reactions, with less trauma and rapid recovery, which shows good potential for use in clinical application.

Spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after gastrectomy for gastric cancer: A case report.

Introduction and importanceSpontaneous gallbladder (GB) perforation is a rare and severe condition. Herein, we present a case of spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after a subtotal gastrectomy for gastric cancer.Case presentationAn 83-year-old woman underwent a radical subtotal gastrectomy for advanced gastric cancer. On postoperative day 5, mild leukocytosis was observed. A computed tomography (CT) scan revealed a slightly distended non-thickened GB with minimal air and fluid collection near the duodenal stump, and fluid collection in the abdominal and pelvic cavities. We considered a duodenal stump leak. The effluent of the Barovac located in the abdominal cavity was serosanguinous and the patient was stable, thus we observed and continued using antibiotics. On day 13, the Barovac stopped functioning properly, so we replaced it with a percutaneous catheter drain (PCD) under ultrasonography guidance, aided by the Barovac tract. The PCD drained over 1000 cc of bile daily. On day 16, a follow-up CT showed an increased fluid collection in the abdominopelvic cavity. After comparing this with the previous CT, we rediagnosed as spontaneous GB perforation. An emergency cholecystectomy was performed. Postoperatively, the patient's condition returned to normal and antibiotic therapy continued until day 14. The patient recovered without other complications and was discharged on day 28.Clinical discussionSpontaneous GB perforation is a rare but serious complication immediately after gastrectomy which should be looked out for.ConclusionWe report a rare case of spontaneous GB perforation mimicking duodenal stump leak after radical subtotal gastrectomy in gastric cancer.

Gastrectomy for elderly gastric cancer patients: A propensity score-matching analysis.

Although D2-gastrectomy is the most effective treatment for resectable gastric cancer (GC), it is unclear whether elderly patients have increased risk of morbidity and worse survival. This study aimed to compare the short- and long-term outcomes of older age (OA) patients with those of less advanced age (LAA). GC patients undergoing curative gastrectomy were retrospectively analyzed and divided into two groups: OA (>75 years) and LAA (<75 years). Propensity score-matching (PSM) analysis using seven variables was conducted to reduce selection bias. Among 586 patients, 494 (84.3%) were classified as LAA and 92 (15.7%) as OA. OA patients had worse clinical status, higher rates of D1-lymphadenectomy, subtotal gastrectomy, and Lauren type; higher mortality and worse survival. No difference in pathological tumor-node-metastasis (pTNM) stage was observed between groups. Preoperative chemotherapy was performed more frequently in the LAA group. After PSM (92 OA: 92 LAA), all variables included in PSM were matched, and mortality rates and survival became similar between groups. In multivariate analysis, American Society of Anaesthesiologists score III/IV was an independent factor associated with a 90-day mortality after PSM. Gastrectomy in elderly GC patients has similar outcomes compared with younger ones. Clinical status and disease stage are more important than the patient's age.

Outcomes of oncologic robotic gastrectomy compared with open gastrectomy for early and locoregional advanced gastric cancer

Abstract Objective Minimally invasive gastrectomy for gastric cancer shows slower adoption in Western countries compared to Asia, probably due to lower incidence, advanced stages and a more frequently proximal localization, which requires a technically more challenging total gastrectomy. Methods We retrospectively reviewed a prospectively collected database. A total of 51 patients who underwent oncologic total gastrectomy or subtotal gastrectomy by robotic or open approach of stage pT1-T4a, pN0-3 were identified from June 2016 until June 2020. Nine patients were operated on robotically, and 42 patients by laparotomy. Perioperative outcomes, postoperative 30-day complications as well as pathologic results were compared. Results The age of the patients in the robotic group was comparable to that of the open group (64.7 ±9.2 versus 62.8 ±12.9, respectively, p = 0.685). Blood loss was significantly smaller with the robotic approach (185±180 mL versus 425±257 mL, p = 0.038). Pathologic tumor stage included stages pT1–pT4b in the open group, while only stages pT1–pT3 were operated by robotic approach. Fewer tumors were localized in the upper body in the robotic group (0, 0%) than in the open group (12, 28.6%). The length of the proximal margin was comparable in the two groups (104.29 ± 50.29 versus 86.88 ± 64.66, p = 0.516). The mean number of retrieved lymph nodes was comparable in the robotic group and the open group (42.89 ± 12.119 versus 43.22 ± 20.271, p = 0.963). The mean number of metastatic nodes was significantly lower in the robotic group (0.33 ± 0.707 versus 7.02 ± 14.313, p = 0.171). In regards to Lauren classification, diffuse-type cancers were significantly more frequent in the robotic group (3 (33.3%) versus 3 (8.6%), respectively, p = 0.040). Significantly fewer high-grade complications (Clavien/Dindo &amp;gt;3a) appeared in the robotic group (0 (0%) versus 2 (4.8%), p = 0.019). No anastomotic leakage and no death occurred in both groups. Conclusion The gold standard of oncologic gastrectomy, especially for advanced stages and bulky lymph nodes, is still the open approach. The minimally invasive approach for gastric cancer may be beneficial in regards to blood loss and postoperative complications but must show comparable pathohistological results in comparison to the open approach in regards to lymph node harvest and proximal tumor margins to be an acceptable alternative to the open approach.