Circular Stapled Gastrojejunostomy after Radical Subtotal Gastrectomy: Anastomotic Bleeding and Prevention

PURPOSE: Circular stapled gastrectomy has been the favored procedure with its feasibility and the shortened operative time, but anastomotic leakage, stenosis and bleeding have been reported as problems. The aim of this study was to identify what can be done to supplement the safety of this technique by examining the potential complications of performing circular stapled gastrojejunosomy after radical subtotal gastrectomy. MATERIALS AND METHODS: As subjects, this study selected 1,391 patients who underwent gastrojejunostomy after radical subtotal gastrectomy because of gastric cancer at our Department of Surgery from Jan. 1998 to Dec. 2007. The patients were divided into Group I (n=479) who underwent hand-sewn gastrojejunostomy, Group II (n=48) who underwent linear stapled gastrojejunostomy and Group III (n=864) who underwent circular stapled gastrojejunostomy. Group III was re-divided into two subgroups on the basis of the point of time that a visual check was intraoperatively performed at the anastomotic site: Group III-A (n=198) before and Group III-B (n=666) after. The characteristics and complications of the patients were then compared. RESULTS: For the comparison of the complications between Group I, Group II and Group III, anastomotic leakage was found in 7 cases (1.5%) in Group I, in 1 case (2.0%) in Group II and in 10 case (1.2%) in Group III, and anastomotic stenosis were found in 4 cases (0.8%) in Group I, 1 case (2.0%) in Group II and 5 case (0.6%) in Group III. Anastomotic bleeding was found in 32 cases (6.7%) in Group I, in 5 cases (10.4%) in Group II and in 67 cases (7.7%) in Group III. For the comparison of complications between Group III-A and Group III-B, anastomotic bleeding was found in 57 cases (28.8%) in Group III-A and 10 cases (1.5%) in Group III-B and the difference was statistically significant (P=0.037). CONCLUSION: Circular stapled gastrojejunostomy after radical subtotal gastrectomy is recommended because of the safety and feasibility of this technique, but bleeding at the anastomotic site may be the critical issue. In conclusion, direct inspection for bleeding at the anastomotic site during the operation will improve the safety of performing circular stapler anastomosis.

Foreign Body Granulomas Simulating Recurrent Tumors in Patients Following Colorectal Surgery for Carcinoma: a Report of Two Cases

We report here two cases of foreign body granulomas that arose from the pelvic wall and liver, respectively, and simulated recurrent colorectal carcinomas in patients with a history of surgery. On contrast-enhanced CT and MR images, a pelvic wall mass appeared as a well-enhancing mass that had invaded the distal ureter, resulting in the development of hydronephrosis. In addition, a liver mass had a hypointense rim that corresponded to the fibrous wall on a T2-weighted MR image, and showed persistent peripheral enhancement that corresponded to the granulation tissues and fibrous wall on dynamic MR images. These lesions also displayed very intense homogeneous FDG uptake on PET/CT.

Step-by-step Management and Treatment Outcome of Bleeding Control for Anastomosis Site after Low Anterior Resection with Double Stapling Technique

PURPOSE: This study reviews our experience with a step- by-step management approach of increasing aggressiveness and evaluates the treatment outcome for intraluminal hemorrhage. METHODS: The study group was comprised of patients who had experienced intraluminal hemorrhage after a low anterior resection with the double stapling technique from 1999 to 2003. The choice of management was selected according to our step-by-step management protocol, and the outcomes were evaluated for each step, lincluding mortality and complications. RESULTS: Nine patients (6 males and 3 females, mean age 55 years) were identified, the mean volume of packed RBC transfusion was 2 pints, and the mean distance of the anastomotic site from the anal verge was 6 cm. The median stapler size was 31 mm. The first step was cold saline irrigation and drainage; four of 9 patients were controlled. The second step was retention enema with topical hemostatics; one of remaining 5 patients stopped bleeding. The third step was colonoscopic hypertonic saline injection around the bleeding site with direct colonoscopic electrocauterization, two of remaining 4 patients were controlled. The last step was suturing the bleeding site through the anus, the remaining 2 patients stopped bleeding. One of the 9 patients developed leakage from the anastomotic site after the last step management, three of the 9 patients had long standing ileus, and one of the 9 patients developed acute renal failure after a massive transfusion. There were no postoperative deaths. CONCLUSIONS: It is safer and easier to control bleeding with step-by-step management system of increasing aggressiveness.

Identification of Lymph Node Micrometastases in Dukes' B Colorectal Cancer Patients Using Monoclonal Antibodies against Cytokeratin-19

PURPOSE: The aims of this study were to immunohistochemically identify lymph node micormetastases in Dukes' B colorectal cancer patients, and determine the relationship between lymph node micrometastases and other prognostic factors and recurrence rates. METHODS: A retrospective analysis was conducted of 990 lymph nodes from Dukes' B 42 patients who had undergone radical colorectal resection. These lymph nodes were immunohistochemically examined with monoclonal antibodies against cytokeratin-19. The prognostic factors and recurrent rates were compared between patients with and without lymph node micrometastases. RESULTS: Micrometastases were confirmed in 19 nodes (1.9%) from 9 patients (21.4%). No correlations were observed between micrometastases and the prognostic factors, with the exception of the preoperative CEA level. 8 of the 9 (88.9%) patients with micrometastases had preoperative CEA levels significantly elevated above 5 ng/ml (P<0.0001). There were no significant differences in the recurrent rates (P=0.0572) between patients with and without micrometastases during the short term follow up period (14.8 months) at the 95% confidence interval, but there were significant differences at the 90% confidence interval. CONCLUSION: High preoperative CEA levels increase the risk for micrometastases, and the presence of micrometastases might increase the possibility of recurrence. Thus, a routine immunohistochemical technique for identifying micrometastases is recommended in the patients with a high preoperative CEA level. However, a more definite clinical significance of lymph node micrometastases awaits further extensive prospective studies.

Identification of Lymph Node Micrometastases in Dukes' B Colorectal Cancer Patients Using Monoclonal Antibodies against Cytokeratin-19

PURPOSE: The aims of this study were to immunohistochemically identify lymph node micormetastases in Dukes' B colorectal cancer patients, and determine the relationship between lymph node micrometastases and other prognostic factors and recurrence rates. METHODS: A retrospective analysis was conducted of 990 lymph nodes from Dukes' B 42 patients who had undergone radical colorectal resection. These lymph nodes were immunohistochemically examined with monoclonal antibodies against cytokeratin-19. The prognostic factors and recurrent rates were compared between patients with and without lymph node micrometastases. RESULTS: Micrometastases were confirmed in 19 nodes (1.9%) from 9 patients (21.4%). No correlations were observed between micrometastases and the prognostic factors, with the exception of the preoperative CEA level. 8 of the 9 (88.9%) patients with micrometastases had preoperative CEA levels significantly elevated above 5 ng/ml (P<0.0001). There were no significant differences in the recurrent rates (P=0.0572) between patients with and without micrometastases during the short term follow up period (14.8 months) at the 95% confidence interval, but there were significant differences at the 90% confidence interval. CONCLUSION: High preoperative CEA levels increase the risk for micrometastases, and the presence of micrometastases might increase the possibility of recurrence. Thus, a routine immunohistochemical technique for identifying micrometastases is recommended in the patients with a high preoperative CEA level. However, a more definite clinical significance of lymph node micrometastases awaits further extensive prospective studies.

Uncut Roux Procedure after Total Gastrectomy

The Roux-en-Y esophagojejunostomy is one of the most common means of reconstructive surgery after a total gastrectomy. While these Roux operations work well in the majority of patients, approximately 30% of individuals undergoing them develop the so-called Roux stasis syndrome, consisting of chronic abdominal pain, nausea, vomiting, and postprandial bloating. The Roux stasis syndrome is thought to result from the jejunal transsection performed during the construction of a conventional Roux limb. The aim of this study was to review a new type of uncut Roux procedure, in which staple lines and loop ligation maintain myoneural continuity and prevent the Roux stasis syndrome between the proximal jejunum and the Roux limb. At the same time, a jejunojejunostomy provides distal diversion of pancreaticobiliary secretions. The postoperative courses of 23 cases of the uncut Roux procedure with staples after a total gastrectomy were compared with those of 18 cases of afferent proximal loop ligation with hand-sewn sutures, the procedures having been performed between May 1995 and January 1997. Passage of contrast media through the ligated afferent jejunal loop was identified in 34.8% of cases and occluded staple lines was identified in 38.9% of cases. It was found that the uncut Roux procedure prevents the Roux stasis syndrome and that the current technique has a high incidence of dehiscence of the staple lines and the loop ligation with subsequent reflux esophagitis. Because of the results reported here, other techniques, which maintain enteric myoneural continuity to an uncut Roux limb while providing complete and permanent diversion of the alkaline secretions distally from the esophagus, need to be developed before this type of anatomic reconstruction can be recommended.