Total Gastrectomy Patients Research Articles

Impact of Various Types of Comorbidities on the Outcomes of Laparoscopic Total Gastrectomy in Patients with Gastric Carcinoma.

PurposeWith increasing life expectancy, the presence of comorbidities has become a major concern in elderly patients who require surgery. However, little is known about the impact of different comorbidities on the outcomes of laparoscopic total gastrectomy (LTG). In this study, we investigated the impact of comorbidities on postoperative complications in patients undergoing LTG for gastric carcinoma.Materials and MethodsWe retrospectively reviewed the cases of 303 consecutive patients who underwent LTG for gastric carcinoma between 2005 and 2016. The associations between each comorbidity and postoperative complications were assessed using univariate and multivariate analyses.ResultsA total of 189 patients (62.4%) had one or more comorbidities. Hypertension was the most common comorbidity (37.0%), followed by diabetes mellitus (17.8%), chronic viral hepatitis (2.6%), liver cirrhosis (2.6%), and pulmonary (27.1%), ischemic heart (3.3%), and cerebrovascular diseases (2.3%). The overall postoperative morbidity and mortality rates were 20.1% and 1.0%, respectively. Patients with pulmonary disease significantly showed higher complication rates than those without comorbidities (32.9% vs. 14.9%, respectively, P=0.003); patient with other comorbidities showed no significant difference in the incidence of LTG-related complications. During univariate and multivariate analyses, pulmonary disease was found to be an independent predictive factor for postoperative complications (odds ratio, 2.14; 95% confidence interval, 1.03–4.64), along with old age and intraoperative bleeding.ConclusionsAmong the various comorbidities investigated, patients with pulmonary disease had a significantly higher risk of postoperative complications after LTG. Proper perioperative care for optimizing pulmonary function may be required for patients with pulmonary disease.

Impact of Body Mass Index on the Quality of Life after Total Gastrectomy for Gastric Cancer.

PurposeWe evaluated the impact of postoperative body mass index (BMI) shifts on the quality of life (QoL) following total gastrectomy in patients with gastric cancer.Materials and MethodsQoL data collected from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and QLQ-STO22 questionnaires were obtained from 417 patients preoperatively and 1 year after surgery. Patients were divided into two groups based on changes in BMI: group 1 comprised patientswhose BMIrange category dropped, and group 2 included patients who maintained or rose to a higher category compared to their preoperative BMI category.ResultsThere were 276 patients in group 1 and 141 in group 2. QoLs with respect to the global health status and functional scales were not significantly different between the groups 1 year after surgery. However, there were significantly greater decreases in QoL in group 1 due to gastrointestinal symptoms, such as nausea and vomiting (p=0.008), appetite loss (p=0.001), and constipation (p=0.038). Of the QLQ-STO22 parameters, dysphagia (p=0.013), pain (p=0.012), reflux symptoms (p=0.017), eating restrictions (p=0.007), taste (p=0.009), and body image (p=0.009) were associated with significantly worse QoL in group 1 than in group 2 1 year after surgery.ConclusionPatients have significantly different QoLs depending on the BMI shift after total gastrectomy. Efforts to reduce the gap in QoL should include intensive nutritional support and restoration of dietary behaviors. Appropriate clinical and institutional approaches, plus active medical interventions, are required for maintaining patients’ BMIs after surgery.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection

BackgroundFeeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. MethodsConsecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009–2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. ResultsThe study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6–8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. ConclusionsSmall bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

Resultados de la manometría del cuerpo esofágico y del asa de yeyuno en pacientes operados por cáncer gástrico con gastrectomía total 5 años después de la cirugía

IntroductionThe most preferred technique to reconstruct the intestinal transit after total gastrectomy for gastric cancer is the Roux-en-Y esophagus-gastrostomy which prevents the reflux of alkaline intestinal juice. The purpose of this study was to analyze the esophageal motility and the motility of the jejunal loop in patients subjected to total gastrectomy. Patients and methodA prospective sample of 17 total gastrectomy patients operated on 5 years before was studied using high resolution esophageal manometry including the first 7cm of the jejunal loop. ResultsManometry results showed normal esophageal body motility with the exception of the maximum intrabolus pressure that was elevated in all patients. The jejunal loop motility was disordered and ineffective. ConclusionsEsophageal body motility was normal 5 years after the surgical procedure. However, maximum intrabolus pressure was elevated and the most plausible reason would be the jejunal loop that exerts resistance to the bolus passage due to its ineffective motility. However, this fact does not have a significant clinical impact.

Resultados del tratamiento quirúrgico en pacientes con cáncer gástrico de 80 o más años

IntroductionThe longevity of Chilean population has increased greatly in the last 25 years, similar to world population. Gastric cancer in Chile is the first cause of death due to malignant tumors. PurposeTo determine operative mortality of subtotal or total gastrectomy in patients with gastric cancer older than 80 years, and the rate 5 year-survival. Material and methodThis is an retrospective-prospective study of all patients with 80 years of age or more submitted to gastric resection due to gastric cancer between 1988 and 2016. Patients submitted to non-resective procedures were excluded. The following parameters were analized: symptoms and signs, comorbidities, pathologic features of the gastric cancer, operative mortality according to the gastrectomy and 5-year survival rate. ResultsThere were 70 patients with gastric cancer older than 80 years of age, which represented 7.4% of all patients with gastric cancer submitted to gastric resection in the same period of time. Most frequent symptoms were epigastric pain, loss of weight and chronic microcitic anemia. There were 66% of the patients with comorbidities. The tumor was located mainly in the upper third of the stomach, being an adenocarcinoma in 66 patients (94%). There were also 2 linfomas, one GIST and one patient with a malignant carcinoid. Early cancer was observed in 12% of the adenocarcinomas. Global operative mortality was 17% being 5% for subtotal and 22% for total gastrectomy. Mean 5-year survival rate was 26%. ConclusionsSubtotal or total gastrectomy in patients with gastric cancer with 80 years of age or more is possible to perform in selected patients, but the risk of operative mortality is 7 to 10 times greater than below 75 years of age.

TREATMENT OUTCOMES OF PROXIMAL GASTRIC CANCER DEPENDING ON THE EXTENT OF SURGICAL RESECTION

Surgical resection for proximal gastric cancer remains an important problem of oncology. Personalized surgical management represents one of the main challenges in treating gastric cancer. The aim of the study was to analyze surgical outcomes of proximal gastric cancer depending on the tumor spread, extent of surgery and the presence of intraperitoneal free cancer cells. Material and Methods. The study included 68 patients with morphologically verified locally advanced proximal gastric cancer. The patients were divided into 2 groups. Group I consisted 37 patients, who underwent total gastrectomy of 31 patients; Group II comprised who underwent proximal subtotal gastrectomy. Results. The overall three-year survival was 48.7 ± 16.9 % in Group I and 66.4 ± 13.2 % in Group II patients. The 3-year progressive-free survival rate was 51.5 ± 18.5 % after proximal subtotal gastrectomy and 34.8 ± 25.6 % after total gastrectomy. The presence of tumor cells in the abdominal cavity was proven to lead to early carcinomatosis. Thus, the 2-year overall survival rate was 26.7 ± 42.8 % in patients in whom free cancer cells were found in peritoneal washings and 69.8 ± 9.0 % in patients with negative cytology findings from washings. Conclusion. Proximal subtotal gastrectomy provides better survival rates compared to total gastrectomy in patients with locally advanced proximal gastric cancer. Local spread of the tumor, which is known to significantly increase the risk of lymph node metastasis and contamination of the peritoneal cavity with cancer cells, is one of the main unfavorable prognostic factors.

Using of Ileucecal Interposition as a Neo-stomach in Dogs with Total Gastrectomy (Presentation of a Novel Technique).

Total gastrectomy and R&Y reconstruction is the standard treatment of gastric cancer except distal form one. Malnutrition is a common adverse effect of this technique, and in this study, we preset a novel technique in order to help to reduce the rate of it. We use seven dogs as participants and after total gastrectomy; we used the 10cm of the ileum and its concomitant cecum as a neo-stomach in them. For 3months, the dogs were evaluated in nutrition status. Three of the dogs died-one due to endocarditis and two due to internal hernia. No anastomosis leakage or stricture was seen and there were no unusual neo-stomach dilation or food stasis. This technique can help the nutrition status of total gastrectomy patients but needs more comparative human studies.

Anemia after gastrectomy in long-term survivors of gastric cancer: A retrospective cohort study

IntroductionThe prevalence of gastric cancer in Korea is increasing, and anemia is one of the most common complications of a gastrectomy. The purpose of this study was to estimate the incidence of anemia and assess its associated factors in long-term gastric cancer survivors. MethodsThis study was a retrospective cohort study of gastric cancer patients who visited a single medical center from January 2009 to December 2014 in Korea. We included 385 patients who survived for at least five years after gastrectomy with no recurrence or metastasis. Anemia was defined by World Health Organization criteria (Hb < 12 g/dL in women and <13 g/dL in men). ResultsHemoglobin levels decreased from 14.24 ± 1.23 mg/dL before surgery to 13.60 ± 1.57 mg/dL one year after surgery (P < 0.001). The cumulative incidence rate of anemia after surgery increased linearly from 18.7% in the first year to 39.5% in the fifth year. The risk of anemia was higher in females (RR, 2.00; 95% CI, 1.26–3.18), patients that received total gastrectomy (RR, 3.00; 95% CI, 2.09–4.30) and patient with diabetes (RR, 1.87; 95% CI, 1.05–3.22). A higher postoperative BMI decreased the risk of anemia (RR, 0.38; 95% CI, 0.22–0.67). ConclusionsDuring five years of follow-up after gastrectomy, the incidence of anemia steadily increased, and the risk of anemia was higher in females, total gastrectomy patients, patients with diabetes, low BMI patients.

Total gastrectomy-induced reductions in food intake and weight are counteracted by rikkunshito by attenuating glucagon-like peptide-1 elevation in rats

Decrease in appetite and weight after total gastrectomy in patients with gastric cancer leads to a decrease in quality of life, increased mortality, and may necessitate discontinuation of adjuvant chemotherapy. The aim of this study is to determine whether rikkunshito, a Japanese herbal medicine, increases food intake and weight after gastrectomy in rats. Male rats underwent gastrectomy followed by roux-en-Y reconstruction or sham operation and were then treated with rikkunshito for 14 days starting on postoperative day 3. Daily food intake, weight, plasma glucagon-like peptide-1 (GLP-1), and ghrelin levels were measured. A pilot study to measure pre- and postoperative plasma GLP-1 levels was conducted in patients who underwent total gastrectomy for gastric cancer. Administration of rikkunshito after gastrectomy in rats significantly increased food intake and weight, which continued for at least 2 weeks after treatment. Both fasting and postprandial plasma GLP-1 levels were increased markedly after gastrectomy compared with sham-operated animals. Increased GLP-1 levels in rats after gastrectomy were suppressed markedly by rikkunshito. rikkunshito had no significant effect on plasma ghrelin levels after gastrectomy. Treatment with a GLP-1 receptor antagonist significantly improved food intake and weight after gastrectomy. Plasma fasting GLP-1 levels in patients with gastric cancer were increased greatly after gastrectomy on postoperative day 1. Administration of rikkunshito suppresses plasma GLP-1 levels after total gastrectomy, which is associated with recovery from reduced food intake and weight in rats.

Comparison of two types of digestive tract reconstruction after total gastrectomy in patients with gastric carcinoma

To evaluate the influence of two different types of digestive tract reconstruction on the life quality, nutritional status and tolerance to adjuvant chemotherapy after total gastrectomy in patients with gastric carcinoma. The clinical data of a total of 107 patients treated in our department from January 2005 to december 2008 were analyzed retrospectively. Among them, 49 patients underwent digestive tract reconstruction with functional jejunal interposition (FJI group) and 58 patients underwent Roux en-Y jejunal P-type anastomosis (PR group) after total gastrectomy. 79 of 107 (73.8%) patients received postoperative adjuvant chemotherapy with XELOX regimen. The digestive complications and tolerance to chemotherapy were assessed respectively. Neither severe complications nor surgery-related or chemotherapy-related death were observed among the 107 patients. There were statistical differences in the incidence rate of emaciation, dumping syndrome and retention syndrome between the FJI and PR groups (P < 0.05), but no significant statistical difference in incidence rate of reflux esophagitis (P > 0.05). 28 of 40 (70.0%) patients in the FJI group completed all six cycles of chemotherapy, while 12 (30.0%) patients interrupted the treatment due to chemotherapy-related toxicity. 39 patients in the PR group received chemotherapy, 19 (48.7%) of them completed 6 cycles of chemotherapy but 20 (51.3%) patients interrupted. There was a significant difference in the incidence rate of grade III/IV chemotherapeutic toxicity and completion rate of chemotherapy (P < 0.05). Both functional jejunal interposition and Roux-Y operation are reasonable and safe procedures of digestive tract reconstruction. The incidence rates of emaciation, dumping syndrome and retention syndrome are lower in the patients with FJI, showing a better tolerance to adjuvant chemotherapy than Roux en-Y jejunal p type anastomosis.

Serial comparisons of quality of life after distal subtotal or total gastrectomy: what are the rational approaches for quality of life management?

PurposeThe aims of this study were to make serial comparisons of the quality of life (QoL) between patients who underwent total gastrectomy and those who underwent distal subtotal gastrectomy for gastric cancer and to identify the affected scales with consistency.Materials and MethodsQoL data of 275 patients who were admitted for surgery between September 2008 and June 2011 and who underwent subtotal gastrectomy or total gastrectomy were obtained preoperatively and postoperatively at 3, 6, 9, 12, 18, and 24 months. The Korean versions of the European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and the gastric cancer specific module, the EORTC QLQ-STO22, were used to assess QoL.ResultsQoL, as assessed by the global health status/QoL and physical functioning, revealed a brief divergence with worse QoL in the total gastrectomy group 3 months postoperatively, followed by rapid convergence. QoL related to restrictive symptoms (nausea/vomiting, dysphagia, reflux, and eating restrictions) and dry mouth was consistently worse in the total gastrectomy group during the first 2 postoperative years.ConclusionsThe general QoL of patients after gastrectomy is highly congruent with subjective physical functioning, and the differences between patients who undergo total gastrectomy and subtotal gastrectomy are no longer valid several months after surgery. In order to further reduce the differences in QoL between patients who underwent total gastrectomy and subtotal gastrectomy, definitive preoperative informing, followed by postoperative symptomatic management, of restrictive symptoms in total gastrectomy patients is the most rational approach.

Comparison of Perioperative and Long‐term Outcomes of Total and Proximal Gastrectomy for Early Gastric Cancer: A Multi‐institutional Retrospective Study

Various surgical procedures are used to treat early gastric cancers in the upper third of the stomach (U-EGCs). However, there is no general agreement regarding the optimal surgical procedure. The medical records of 203 patients with U-EGC were collected from 13 institutions. Surgical procedures were classified as Roux-en-Y esophagojejunostomy after total gastrectomy (TG-RY), esophagogastrostomy after proximal gastrectomy (PG-EG), or jejunal interposition after PG (PG-JI). Patient clinical characteristics and perioperative and long-term outcomes were compared among these three groups. TG-RY, PG-EG, and PG-JI were performed in 122, 49, and 32 patients, respectively. Tumors were larger in TG-RY patients than in PG-EG and PG-JI patients, and undifferentiated-type gastric adenocarcinoma tended to be more frequent in TG-RY than in PG-EG. The operative time was shorter for PG-EG than for PG-JI and TG-RY. Hospital stay and early postoperative complications were not different for the three procedures. With respect to gastrectomy-associated symptoms, a "stuck feeling" and heartburn tended to be more frequent in PG-EG patients, while dumping syndrome and diarrhea were more frequent in TG-RY patients. Post-surgical weight loss was not different among the three groups, however, serum albumin and hemoglobin levels tended to be lower in TG-RY patients. Three surgical procedures for U-EGC did not result in differences in weight loss, but PG-EG and PG-JI were better than TG-RY according to some nutritional markers. In U-EGC, where patients are expected to have long survival times, PG-EG and PG-JI should be used rather than TG-RY.

P3–054 - Reconstruction After Total Gastrectomy in Patients with Gastric Cancer: Our Hospital Experience

Background and aims: Gastric cancer (GC) remains one of most worldwide frequent cancers. After total gastrectomy it is necessary to realize reconstructin of the upper part digestive tract. The double tract (DT) method is the optimal reconstruction procedure after total gastrectomy for patients with gastric cancer.Methods: In General hospital Sveti Vraceviin Bijeljina from January 2006 to January 2012, 67 patients who underwent a total gastrectomy with a curative resection. In all patients to the esophagojejunostomy, the side-to-end jejunoduodenostomy was performed manually, 35 cm distal to the esophagojejunal anastomosis. The end of the Y limb was anastomosed manually to the side of the Roux limb, approximately 15 cm distal to the jejunoduodenal anastomosis. It is prospectively study for all patients and included their history, clinicopathologic examinations, postoperative clinical information, and complications.Results: In these study were observed early postoperative complications and mortality, postoperative food intake and nutritional status (hemoglobin, total proteins and albumin), and incidence of diarrhea and dumping syndrome at 1 and 5 years. The overall 1-, 3-, and 5-year cumulative survival rate were 53.3%, 24.6%, and 10.8%, respectively. Concerning tumor location, tumor diffused in thee sections of stomach in 67 cases, mainly in cardia and body in 20 cases, mainly in body and antrum in 36 cases, and only in body of stomach in 11 cases. In the pathological examination, the tumors of 57 patients were diagnosed as adenocarcinoma, 7 as malignant lymphoma, and 3 as leiomyosarcoma.Conclusions: The benefits of this method are (1) a simple procedure; (2) preservation of the duodenal passage; (3) no duodenal stump, resulting in no risk of postoperative stump rupture. Background and aims: Gastric cancer (GC) remains one of most worldwide frequent cancers. After total gastrectomy it is necessary to realize reconstructin of the upper part digestive tract. The double tract (DT) method is the optimal reconstruction procedure after total gastrectomy for patients with gastric cancer. Methods: In General hospital Sveti Vraceviin Bijeljina from January 2006 to January 2012, 67 patients who underwent a total gastrectomy with a curative resection. In all patients to the esophagojejunostomy, the side-to-end jejunoduodenostomy was performed manually, 35 cm distal to the esophagojejunal anastomosis. The end of the Y limb was anastomosed manually to the side of the Roux limb, approximately 15 cm distal to the jejunoduodenal anastomosis. It is prospectively study for all patients and included their history, clinicopathologic examinations, postoperative clinical information, and complications. Results: In these study were observed early postoperative complications and mortality, postoperative food intake and nutritional status (hemoglobin, total proteins and albumin), and incidence of diarrhea and dumping syndrome at 1 and 5 years. The overall 1-, 3-, and 5-year cumulative survival rate were 53.3%, 24.6%, and 10.8%, respectively. Concerning tumor location, tumor diffused in thee sections of stomach in 67 cases, mainly in cardia and body in 20 cases, mainly in body and antrum in 36 cases, and only in body of stomach in 11 cases. In the pathological examination, the tumors of 57 patients were diagnosed as adenocarcinoma, 7 as malignant lymphoma, and 3 as leiomyosarcoma. Conclusions: The benefits of this method are (1) a simple procedure; (2) preservation of the duodenal passage; (3) no duodenal stump, resulting in no risk of postoperative stump rupture.

Long-term outcomes of patients who underwent limited proximal gastrectomy

Because the incidence of early gastric cancers has been increasing in Asian countries, postoperative quality of life has received considerable attention in addition to oncological outcomes. Eighty-four patients with clinically early gastric cancers were enrolled in this retrospective study. Among them, 35 patients underwent total gastrectomy (TG) and 49 patients underwent limited proximal gastrectomy (PG). Blood chemistry, changes in body weight, and oncological outcomes were compared between the two groups. Postoperative hemoglobin levels and body weights were significantly lower in the TG group than in the PG group, and there were no significant differences in the levels of other nutritional indicators such as serum total protein and total cholesterol. However, the overall survival rates of patients in the PG group were similar to those of patients in the TG group (5-year survival rates, 95 versus 97 %, respectively; p = 0.86). Limited proximal gastrectomy with regional lymph node dissection has possible positive effects on maintaining body weight and preventing postgastrectomy anemia with similar oncological outcomes to total gastrectomy in patients with early gastric cancers.

Feasibility of laparoscopy-assisted total gastrectomy in patients with clinical stage I gastric cancer

Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer is not yet widespread because of the technical difficulty of reconstruction. We have performed LATG on 100 patients with clinical stage I gastric cancer. This study investigated the short-term outcomes of LATG. Between September 2001 and September 2012, 100 patients with clinical stage I gastric cancer underwent LATG with D1 plus beta or D2 lymphadenectomy. Roux-en-Y esophagojejunostomy was performed intracorporeally using end-to-side anastomosis with a circular stapler (the purse-string suture method). The primary endpoint was the proportion of postoperative complications during hospitalization. Mean operation time was 249 min; mean blood loss was 182 ml. There were no conversions to open surgery. According to the Clavien-Dindo classification, there were 8 grade II (8 %) and 10 grade IIIa/b (10 %) complications. There were no treatment-related deaths or grade IV complications. The most frequent complication was anastomotic or stump leakage (6 %), followed by pancreatic fistula (5 %). Reoperations were required in two patients with leakage. The short-term outcomes of LATG in our study involving 100 patients were outlined. LATG for gastric cancer patients should be attempted preferably in a clinical trial setting by surgeons with sufficient experience in laparoscopic gastrectomy.

Postoperative nutritional effects of early enteral feeding compared with total parental nutrition in total gastrectomy patients

Objective To compare the effect of comparion of the effect of postoperative.Methods Forty patients with total gastrectomy for gastric cancer surgery were randomly divided into groups of early parenteral nutrition (EEN) and total parental nutrition (TPN) group,20 patients in each group.Nutritional index,immune status,complication rate and postoperative intestinal function recovery time and average hospital stay were observed.Results The first day of bowel movement and time to take a normal soft diet was significantly shorter in EEN group than that in TPN group(t =5.091,7.007,all P ＜ 0.05).and the hospital stays of EEN group all so significantly shorter than TPN group (t =5.802,P ＜ 0.05).Prealbumin and transferrin were significantly reduced on post-operative day (POD)7 and were slowly recovered until POD 90.but the increased rate in EEN group was significantly faster than that in TPN group [cprealbumin:t =9.501,7.913,7.182,6.154,all P ＜ 0.05] ; transferrin:t =5.501,5.712,5.733,5.801,all P ＜ 0.05).The TLC,CD4 and CD8 are lower than before total gastrectomy on POD 7,and have been recovered to the level before surgery.The TLC level on POD 7 and 14 were significantly higher in EEN group than that in TPN group (t =5.645,5.134,all P ＜ 0.05).The PG-SGA score was lower in EEN group than that in TPN group,particularly on POD 21 (t =5.211,P ＜ 0.05).Conclusion Total gastreetomy for gastric cancer after curative resection of early enteral nutrition support can improve the postoperative intestinal function recovery and shorten the time of hospital stay for patients. Key words: Enteral nutrition; Parenteral nutrition; Gastrectomy; Stomach neoplasms

Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients

To assess the impact of fast-track surgery (FTS) on hospital stay, cost of hospitalization and complications after radical total gastrectomy. A randomized, controlled clinical trial was conducted from November 2011 to August 2012 in the Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, the Fourth Military Medical University. A total of 122 gastric cancer patients who met the selection criteria were randomized into FTS and conventional care groups on the first day of hospitalization. All patients received elective standard D2 total gastrectomy. Clinical outcomes, including duration of flatus and defecation, white blood cell count, postoperative pain, duration of postoperative stay, cost of hospitalization and complications were recorded and evaluated. Two specially trained doctors who were blinded to the treatment were in charge of evaluating postoperative outcomes, discharge and follow-up. A total of 119 patients finished the study, including 60 patients in the conventional care group and 59 patients in the FTS group. Two patients were excluded from the FTS group due to withdrawal of consent. One patient was excluded from the conventional care group because of a non-resectable tumor. Compared with the conventional group, FTS shortened the duration of flatus (79.03 ± 20.26 h vs 60.97 ± 24.40 h, P = 0.000) and duration of defecation (93.03 ± 27.95 h vs 68.00 ± 25.42 h, P = 0.000), accelerated the decrease in white blood cell count [P < 0.05 on postoperative day (POD) 3 and 4], alleviated pain in patients after surgery (P < 0.05 on POD 1, 2 and 3), reduced complications (P < 0.05), shortened the duration of postoperative stay (7.10 ± 2.13 d vs 5.68 ± 1.22 d, P = 0.000), reduced the cost of hospitalization (43783.25 ± 8102.36 RMB vs 39597.62 ± 7529.98 RMB, P = 0.005), and promoted recovery of patients. FTS could be safely applied in radical total gastrectomy to accelerate clinical recovery of gastric cancer patients.

Mortality After Esophageal and Gastric Cancer Resection

Contrasting findings on trends and determinants of operative mortality after surgery for esophageal and gastric cancer have been reported from population-based studies. Discharge records of residents in the Veneto Region (northeastern Italy) with a diagnosis of esophageal or gastric cancer and intervention codes for esophagectomy or gastrectomy were extracted for the years 2000-2009. In-hospital, 30-day, 90-day, and perioperative (30-day + in-hospital) mortality were computed. The influence of patient and hospital variables on in-hospital mortality was assessed through multilevel models. Overall, 6,500 resections were performed in the period of 2000-2009, with a 10 % decline in the second half of the study period. In-hospital mortality was 4.6 % (5.3 % in 2000-2004 and 3.8 % in 2005-2009) and was higher for extended total gastrectomy and total esophagectomy. In 2005-2009 mortality declined for all resection types except extended total gastrectomy (8.0 %). For esophageal procedures, 30-day mortality was lower than in-hospital or perioperative mortality. A protective effect of procedural volume was found for esophageal but not for gastric resections; among gastric procedures, mortality was higher in male patients and in extended total gastrectomy patients. Analyses of discharge records allowed investigation at a population level of time trends (downward mainly for esophageal resections) and determinants of perioperative mortality (hospital volume, gender, and procedure type).

Clinical application of immune‐enhanced enteral nutrition in patients with advanced gastric cancer after total gastrectomy

To determine whether immune-enhanced enteral nutrition (EN) was effective on nutritional status, immune function, surgical outcomes and days of hospitalization after total gastrectomy for patients with advanced gastric cancer (AGC). From August 2005 to May 2011, 78 patients with AGC who underwent a total gastrectomy were enrolled and divided randomly into three groups: immune-enhanced EN (EN + glutamine [Gln]) group, standard EN group and control group. Serum parameters including total protein, albumin, proalbumin and transferrin were examined on preoperative day 1, postoperative day 2 and day 12. Levels of immunoglobulin M (IgM), immunoglobulin G (IgG), natural killer (NK) cells, CD4⁺ and CD8⁺ T cells were also compared. The formulas were tolerated well in all the patients except 5 with mild complications. The EN + Gln and EN groups showed a faster onset of flatus and shorter hospitalization duration than the control group. On postoperative day 12, serum total protein, albumin, proalbumin and transferrin levels of the EN + Gln and EN groups were significantly higher than those of the control group (P < 0.05). CD4⁺ T cells, NK cells, IgM and IgG levels of the EN + Gln group increased prominently, and were significantly higher than those before the operation as well as those in the EN and control groups. Immune-enhanced EN can improve nutritional status and immune function for the patients with AGC after total gastrectomy.

The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients with Gastric Cancer: The Randomized Prospective Study

Early enteral nutrition (EEN) has benefits in reducing infectious complication, length of stay (LOS) and preserving liver function. There are few data about the effect of EEN in the patients who had total gastrectomy. The aim of this randomized and prospective study was to evaluate the effect of EEN after total gastrectomy on nutritional status, liver function, complications and LOS, compared to total parenteral nutrition (TPN) in patients with gastric cancer. Among 56 patients with gastric cancer, 36 and 20 were randomly assigned to EEN and TPN groups, and finally 17 and 16 completed EEN and TPN schedules, respectively. The nutritional parameters, liver function, LOS and abdominal symptoms were compared between 2 groups on pre-operative day and post-operative 7th day. There was no significant difference in the nutritional parameters, liver function between EEN and TPN groups. Vomiting and abdominal distention were more frequent in EEN than TPN group (2 vs. 0 cases, p=0.485; 1 vs. 0 case, p=1.000, respectively), while increased AST, ALT and total bilirubin were more common in TPN than EEN group (4 vs. 2 cases, p=0.398; 1 vs. 0 case, p=0.485, respectively without statistical significance). LOS was shorter in EEN than TPN group without statistical significance (12 vs. 13 days, p=0.289). No significant differences were found in the nutritional status parameters, liver function, complications and LOS between EEN and TPN groups on 7th day after total gastrectomy. Further large scale studies on the advantages and disadvantages of EEN after total gastrectomy are warranted.