Research progress in anti-reflux reconstructions and mechanism after proximal gastrectomy / 中华胃肠外科杂志

The electrophysiological activity of the gastrointestinal tract and the mechanical anti-reflux structure of the gastroesophageal junction are the basis of the anti-reflux function of the stomach. Proximal gastrectomy destroys the mechanical structure and normal electrophysiological channels of the anti-reflux. Therefore, the residual gastric function is disordered. Moreover, gastroesophageal reflux is one of the most serious complications. The emergence of various types of anti-reflux surgery through the mechanism of reconstructing mechanical anti-reflux barrier and establishing buffer zone, and the preservation of, the pacing area and vagus nerve of the stomach, the continuity of the jejunal bowel, the original gastroenteric electrophysiological activity of the gastrointestinal tract, and the physiological function of the pyloric sphincter, are all important measures for gastric conservative operations. There are many types of reconstructive approaches after proximal gastrectomy. The design based on the anti-reflux mechanism and the functional reconstruction of mechanical barrier, and the protection of gastrointestinal electrophysiological activities are important considerations for the selected of reconstructive approaches after proximal gastrectomy. In clinical practice, we should consider the principle of individualization and the safety of radical resection of tumor to select a rational reconstructive approaches after proximal gastrectomy.

Current status of lymph node dissection in pyloric-preserving gastrectomy for early gastric cancer / 中华胃肠外科杂志

With the gradual increase in the diagnosis rate of early gastric cancer, clinicians must consider prevention of gastric anatomical structure and physiological function while ensuring the radical treatment of the tumor. Pylorus-preserving gastrectomy is a function- preserving operation that preserves the pylorus, inferior pyloric vessel, and the vagus nerve in patients with early middle gastric cancer. One of the major controversies at present is the thoroughness of limited lymph node dissection for pyloric-preserving gastrectomy. Various studies have reported that the lymph node metastasis rate of early middle gastric cancer was low, especially in the suprapyloric region, inferior pylorus and the upper pancreatic region. Partial lymph node dissection is required for vascular and neurological protection, which is also safe and feasible in studies reported by major centers. Many clinical studies have been carried out in Japan and Korea, and postoperative follow-up has gradually increased evidence, providing the basis for the safety of lymph node dissection. In large case studies comparing pylorus- preserving gastrectomy with traditional distal gastrectomy, the incidence of postoperative morbidity, such as dumping syndrome, bile reflux esophagitis, weight loss, and malnutrition is low. Sentinel lymph node navigation technology is gradually applied to the diagnosis and treatment of early gastric cancer, and its clinical application value still needs further research.

EndoFLIP: una nueva tecnología / EndoFLIP: a new technology

Resumen Mediante la distensión de un balón con líquido conductor, la sonda de imagen luminal funcional endoluminal (EndoFLIP) evalúa las propiedades biomecánicas como la distensibilidad, volumen, presión e inclusive diámetros de regiones esfinterianas como la unión gastroesofágica, píloro y ano. La mayor evidencia en la utilidad clínica de la EndoFLIP está en los trastornos de motilidad esofágica, principalmente para identificar acalasia cuando la manometría esofágica de alta resolución y otras imágenes no logran diagnosticarla e inclusive, mediante el programa de FLIP 2.0, caracteriza la acalasia en subtipos a partir de patrones de motilidad del esófago distal en respuesta a la distensión. Se ha demostrado recientemente que la EndoFLIP tiene un rol diagnóstico, pronóstico o terapéutico en otras patologías como la esofagitis eosinofílica, reflujo gastroesofágico, gastroparesia, durante la fundoplicatura y dilatación esofágica.

Abstract EndoFLIP evaluates biomechanical properties such as distensibility, volume, pressure, and even diameters of sphincter regions like the gastroesophageal junction, pylorus, and anus, by distending a balloon with a conductive medium. The best evidence of the clinical utility of EndoFLIP is observed in esophageal motility disorders, mainly when identifying achalasia when high-resolution esophageal manometry and other images fail to diagnose it. Even EndoFLIP 2.0 characterizes achalasia into subtypes based on distal esophageal motility patterns in response to distention. Recently, it has been shown that this system has a diagnostic, prognostic and/or therapeutic role in other diseases such as eosinophilic esophagitis, gastroesophageal reflux, and gastroparesis, and during fundoplication and esophageal dilation.

Tratamiento endoscópico de la obstrucción del tracto de salida gástrico de origen péptico-cicatricial en un niño de 4 años / Endoscopic treatment of cicatricial pyloric stenosis of peptic origin in a 4-year-old boy

La obstrucción de la salida gástrica es una afección infrecuente en la edad pediátrica. Tradicionalmente, la cirugía ha sido el modo de tratamiento estándar, pero está asociada a mayor morbimortalidad. El tratamiento endoscópico ha surgido como una alternativa al tratamiento convencional. Presentamos el caso de un paciente de 4 años con estenosis prepilórica secundaria a enfermedad ulceropéptica. El cuadro clínico empezó con vómitos y dolor abdominal de 2 meses de evolución. Frente a la falta de respuesta al tratamiento médico y a la dilatación endoscópica con balón, se realizaron incisiones radiadas con electrocauterio e inyecciones de esteroides. La terapéutica endoscópica con balón debería ser el primer gesto terapéutico en este tipo de estenosis refractarias al tratamiento médico

Gastric outlet obstruction is an uncommon condition in children. Traditionally, surgery has been the standard mode of treatment, but it is associated with higher morbidity and mortality. Endoscopic treatment has emerged as an alternative to conventional treatment. We present the case of a 4-year-old patient with refractory prepyloric stenosis secondary to peptic ulcer disease. The picture begins with vomiting and abdominal pain of 2 months of evolution. Pre-pyloric stenosis was confirmed. Faced with the lack of response to medical treatment and balloon dilation, radiated incisions were made with electrocautery and steroid injections. When medical treatment is not sufficient, endoscopic balloon therapy should be the first therapeutic gesture in this type of stenosis; given its refractoriness, we believe it is important to highlight the usefulness of endoscopic treatment, which could prevent surgery and associated morbidity and mortality.

Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer / 中华胃肠外科杂志

Objective: To investigate the safety and feasibility of Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer. Methods: In this study, descriptive case series method was used to retrospectively analyze the data of 3 patients with gastric cancer who underwent Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy in the First Affiliated Hospital of Dalian Medical University from December 2020 to February 2021. The linear layout was adopted for the setting of trocar, and the co-axial direction was the line connecting the umbilicus and splenic hilum. The inferior pyloric arteries and veins need to be preserved. The center was the bifurcation of the right gastroepiploic vessel and the inferior pyloric vessel. Dissection and exposure were performed from the upper, lower, right and left sides, and ventral and dorsal sides to complete the dissection of the inferior pyloric lymph nodes. The superior border of the pancreas was treated by the right diaphragmatic crus approach, the left retroperitoneal approach and the esophageal approach to determine the distribution of the posterior vagal trunk and its branches, and to determine the anatomical relationship with the left gastric artery. The left gastric artery was cut off while the celiac branch of vagus nerve and cardia branch of left gastric artery were preserved. Lymph node dissection was performed on the lateral side of nerve fibers around the blood vessels. Result: All the 3 patients successfully completed the robotic surgery without conversion to laparoscopy or laparotomy. The operation time was (340.0±26.4) (300-390) minutes, the intraoperative blood loss was (13.3±3.3) (10-20) ml, the number of dissected lymph nodes was 26.7±3.9 (19-32), the length of pylorus canal preserved was (3.3±0.3) (3-4) cm, the distal margin was (2.3±0.3) (2-3) cm, and the proximal margin was (3.0±0.6) (2-4) cm. No postoperative complications occurred in all the 3 patients. The first flatus time was 2-3 days after operation, and the postoperative hospital stay was 6-7 days. The operation cost of the 3 patients was (40±7) (33-53) thousand yuan. Conclusion: Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy is safe and feasible.

Pylorus-preserving gastrectomy and segmental gastrectomy: discrimination of concepts and surgical procedures / 中华胃肠外科杂志

Both pylorus-preserving gastrectomy (PPG) and segmental gastrectomy (SG) achieve the preservation of gastric cardia and pylorus through the circumferential resection of stomach, while concepts and surgical procedures of these two operations are obviously different. In this sense, transectional gastrectomy includes both PPG and SG. PPG is one of the standard surgical procedure for early gastric cancer (EGC). The extent of lymph node dissection (No.1, 3, 4sb, 4d, 6, 7, 8a, 9) and the retention of infrapyloric vessels, hepatic and pyloric branch of vagal nerve has formed a consensus. Meanwhile, SG is regarded as an investigational treatment according to the Japanese gastric cancer treatment guidelines. It is still controversial and may generate an ethical risk in the clinical practice. This article distinguishes the difference in the concepts and surgical procedures between PPG and SG, assisting a comprehensive evaluation in further research.

Functional evaluation after function-preserving gastrectomy / 中华胃肠外科杂志

With the increase of people's health awareness and the progress of medical diagostic technology in recent years, the diagnosis rate of early gastric cancer is increasing year by year. Although radical surgery has good efficacy, how to maximize the preservation of the normal anatomy and function of the stomach and improve the quality of life of patients in the pursuit of radical surgery has become a more important issue in the treatment of early gastric cancer. Under the condition of ensuring radical lymph node dissection, function-preserving gastrectomy can fully preserve gastric function by reducing the resection extent and preserving the pylorus and the vagus nerve, which has advantage of improving quality of life and has great potential in the treatment of early gastric cancer. However, there is no functional evaluation standard for function-preserving gastrectomy at present. Most of the patients are evaluated by quality of life scale, which is relatively subjective. Even though the evaluation of endoscopy, hematology and other objective means can indicate the benefit degree in quality of life brought by functional reconstruction, the evidence level is limited. Therefore, this paper discusses the research status of function-preserving gastrectomy evaluation, postoperative complications, postoperative nutritional status, auxiliary examination and other items in the evaluation of gastric function, and analyzes the prospects of research direction in this field.

Choice of function-preserving gastrectomy / 中华胃肠外科杂志

As the diagnosis rate of early gastric cancer is increasing annually, the current hot spot in the treatment of early gastric cancer is how to better preserve the anatomical structure and physiological function of the stomach and improve the quality of life of patients after surgery under the premise of tumor eradication. Therefore, function-preserving gastrectomy has been the trend of surgical treatment for early gastric cancer. It is not just a modified gastrectomy, but a better combination of improved surgical techniques and the concept of function-preserving treatment, rather than being limited to traditional surgical treatments. Currently, the routine function-preserving gastrectomy mainly includes pylorus-preserving gastrectomy, proximal gastrectomy and partial gastrectomy combined with endoscopy. In addition, with the deeper understanding of metastasis pattern of gastric cancer and the development and popularization of minimally invasive techniques, laparoscopic and endoscopic cooperative surgery is gradually gaining attention. The application of laparoscopic and endoscopic hybrid surgery combined with sentinel lymph node navigation is anticipated in the treatment of early gastric cancer.

Infrecuente complicación de páncreas ectópico: obstrucción intestinal por pseudoquiste pancreático en píloro / Infrequent complication of heterotopic pancreas: intestinal obstruction by pancreatic pseudocyst in pylorus

Resumen: Presentamos un caso un hombre de 53 años con antecedentes de reflujo gastroesofágico y pirosis con varias visitas al servicio de urgencias por vómitos, con antecedentes de consumo crónico de alcohol. La TC sin y con contraste endovenoso mostró a nivel del píloro una lesion ovoidea de paredes gruesas con captación similar al tejido pancreático, con un gran componente quístico bien delimitado que condiciona una obstrucción intestinal. La ecografía confirma la presencia de una lesión quística con ecos móviles en su interior. Tras la realización de antrectomía, el estudio histológico revela un pseudoquiste pancreático sobre páncreas ectópico, siendo esta presentación muy infrecuente, con pocos casos descritos hasta la fecha. Conclusión: Los hallazgos clínico-radiológicos con TC y US de páncreas ectópico pueden orientar el diagnóstico, aunque no son concluyentes. El diagnóstico definitivo se realiza mediante estudio histológico.

Abstract: A 53 year-old male with a past history of chronic alcohol intake, presents with an intestinal obstruction. A CT scan shows an ovoid tumor in pylorus with a great cystic component, thick wall and delimited rim, causing gastric retention. Its walls have similar enhancing pattern as the pancreatic tissue. Ultrasound revealed the presence of a cystic tumor with mobile echoes inside. After antrectomy the histological study reports pancreatic pseudocyst hosted in ectopic pancreas. This is an unusual presentation and only a few cases have been reported. Conclusion: The clinical and radiographic findings of ectopic pancreas are non-specific. Definitive diagnostic requires histological study.

Heterotopia pancreática en pólipo gástrico. Presentación de caso / A case of heterotopic pancreas in a gastric polyp

Resumen La heterotopia pancreática es un hallazgo poco frecuente, en ocasiones accidental, que se puede observar en cualquier nivel del tracto digestivo e inclusive fuera del mismo; es congénita y su patogenia está en discusión. Aunque su forma de presentación es lenta y progresiva y su comportamiento benigno y asintomático, en ocasiones puede originar manifestaciones obstructivas, hemorrágicas, inflamatorias y neoplásicas. En este último caso es imprescindible el diagnóstico histopatológico. Se presenta el caso de un paciente sintomático con heterotopia pancreática a nivel del píloro gástrico cuya localización es bastante infrecuente.

Abstract Pancreatic heterotopia is rare and is sometimes found accidentally. It can occur anywhere in the digestive tract and even outside of it. Heterotopic pancreas is congenital, but its pathogenesis is under discussion. Although it develops slowly and progressively, its behavior is benign and asymptomatic. Nevertheless, it can manifest in obstructions, hemorrhaging, inflammation and neoplasia. In the latter case, histopathological diagnosis is essential. We present the case of a symptomatic patient with pancreatic heterotopia at the gastric pylorus, a very uncommon location.

Características morfológicas do estômago de jaguatirica (Leopardus pardalis - Linnaeus, 1758) / Morphological characteristics of the stomach of the ocelot (Leopardus pardalis - Linnaeus, 1758)

Leopardus pardalis é uma das espécies de felinos neotropicais mais estudadas em seus aspectos ecológicos, porém informações de questões morfofisiológicas do trato digestório não são encontradas na literatura. Visando contribuir com tais informações, o objetivo deste artigo foi caracterizar a morfologia do estômago dessa espécie. Nesta pesquisa, foram utilizados cinco exemplares adultos, coletados após óbito por atropelamento ou doados pelo IBAMA ao Laboratório de Zoologia e Morfologia Animal da Universidade do Estado de Mato Grosso - Alta Floresta. Os animais foram fixados com solução aquosa de formaldeído a 10%, dissecados por meio de técnicas anatômicas. Além dos estudos anatômicos, também foram coletados tecidos para microscopia. As análises macroscópicas revelaram que o estômago era do tipo unicavitário, com presença de pequena e grande curvatura, localizado no antímero esquerdo e constituído pelas regiões características do órgão. Em seus aspectos microscópicos, mostrou-se formado pelas quatro túnicas usuais do tubo digestório: túnica mucosa, submucosa, muscular e serosa, cada uma com as particularidades características de cada região, principalmente na túnica mucosa. O estômago de L. pardalis revelou uma morfologia semelhante às espécies domésticas e selvagens, com particularidades histomorfológicas na região pilórica. Esse padrão pode estar relacionado a adaptações evolutivas no processo digestivo dessa espécie.(AU)

The species Leopardus pardalis is one of the species of neotropical felines more studied in its ecological aspects, however, information of morphophysiological questions of the digestive tract are not found in the literature. Aiming to contribute with such information, the objective of this work was to characterize the morphology of the stomach of this species. Five adult specimens, collected after death by trampling, or donated by IBAMA to the Laboratory of Zoology and Animal Morphology of the University of the State of Mato Grosso - Alta Floresta, were used in this research. The animals were fixed with aqueous solution of formaldehyde 10%, dissected through the basic techniques and instruments of anatomy, and later the material was collected for microscopy. The macroscopic analysis revealed that the stomach was of the unicavitary type, with small and great curvature, located in the left antimer and constituted by the characteristic regions of the organ. In its microscopic aspects it was formed by the four usual tunics of the digestive tube: tunica mucosa, submucosa, muscular and serosa, each one with the peculiarities characteristic of each region, mainly in the tunica mucosa. The stomach of L. pardalis revealed similar morphology to the domestic and wild species, with small histomorphological peculiarities in the pyloric region, which may be related to evolutionary adaptations in the digestive process of this species.(AU)

Píloro doble. Presentación de un caso y revisión de la literatura / Double pylorus. Case report and literature review

RESUMEN El doble píloro es una comunicación anormal entre el antro gástrico y el bulbo duodenal y representa un raro hallazgo endoscópico. Se presentó un paciente de 80 años de edad, con antecedentes de hipertensión arterial, fumador inveterado, tomador de aspirina, que presentó melena aproximadamente 15 días antes del ingreso. La videoendoscopia reveló la existencia de dos orificios similares en el antro, que se comunicaban con el bulbo duodenal de manera independiente que fueron catalogados como píloros. La comunicación se constató con el paso del endoscopio a su través. Se impuso tratamiento médico con inhibidores de la bomba de protones y la evolución fue favorable. Es el cuarto caso reportado en la literatura en nuestro país y el primero en la provincia de Matanzas.

ABSTRACT Double pylorus is an abnormal communication between the gastric antrum and the duodenal bulb and represents a rare endoscopic finding. It is presented the case of a patient aged 80 years, with a background of arterial hypertension, inveterate smoker, taking aspirin, who presented melena about 15 days before the admission. The video-endoscopy revealed the existence of two similar orifices in the antrum that were independently communicating with the duodenal bulb and they went catalogued like pylori. The communication was proved by passing the endoscope through it. He was treated with IBP (the Spanish acronym for proton bomb inhibitors) and the evolution was favorable. It is the fourth case reported in the literature in Cuba and the first one in Matanzas.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy

PURPOSE: The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy. MATERIALS AND METHODS: Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10–30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively. RESULTS: Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed. CONCLUSIONS: Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0000823

Topographical anatomy of the greater omentum and transverse mesocolon: a study using human fetuses / 대한해부학회지

Effects of Intraduodenal Infusion of the Bitter Tastant, Quinine, on Antropyloroduodenal Motility, Plasma Cholecystokinin, and Energy Intake in Healthy Men

BACKGROUND/AIMS: Nutrient-induced gut hormone release (eg, cholecystokinin [CCK]) and the modulation of gut motility (particularly pyloric stimulation) contribute to the regulation of acute energy intake. Non-caloric bitter compounds, including quinine, have recently been shown in cell-line and animal studies to stimulate the release of gastrointestinal hormones by activating bitter taste receptors expressed throughout the gastrointestinal tract, and thus, may potentially suppress energy intake without providing additional calories. This study aims to evaluate the effects of intraduodenally administered quinine on antropyloroduodenal pressures, plasma CCK and energy intake. METHODS: Fourteen healthy, lean men (25 ± 5 years; BMI: 22.5 ± 2.0 kg/m²) received on 4 separate occasions, in randomized, double-blind fashion, 60-minute intraduodenal infusions of quinine hydrochloride at doses totaling 37.5 mg (“Q37.5”), 75 mg (“Q75”) or 225 mg (“Q225”), or control (all 300 mOsmol). Antropyloroduodenal pressures (high-resolution manometry), plasma CCK (radioimmunoassay), and appetite perceptions/gastrointestinal symptoms (visual analog questionnaires) were measured. Ad libitum energy intake (buffet-meal) was quantified immediately post-infusion. Oral quinine taste-thresholds were assessed on a separate occasion using 3-alternative forced-choice procedure. RESULTS: All participants detected quinine orally (detection-threshold: 0.19 ± 0.07 mmol/L). Intraduodenal quinine did not affect antral, pyloric or duodenal pressures, plasma CCK (pmol/L [peak]; control: 3.6 ± 0.4, Q37.5: 3.6 ± 0.4, Q75: 3.7 ± 0.3, Q225: 3.9 ± 0.4), appetite perceptions, gastrointestinal symptoms or energy intake (kcal; control: 1088 ± 90, Q37.5: 1057 ± 69, Q75: 1029 ±70, Q225: 1077 ± 88). CONCLUSION: Quinine, administered intraduodenally over 60 minutes, even at moderately high doses, but low infusion rates, does not modulate appetite-related gastrointestinal functions or energy intake.

A Comparison of Totally Laparoscopic Pylorus Preserving Gastrectomy and Laparoscopy-Assisted Pylorus Preserving Gastrectomy for Early Gastric Cancer

PURPOSE: Pylorus-preserving gastrectomy (PPG) is known to have both nutritional and functional advantages over distal gastrectomy for the treatment of early gastric cancer. Although laparoscopic surgery is a popular choice, intracorporeal anastomosis is a newly developed technique that is gaining popularity. This study aimed to determine any differences in the oncological, surgical, and functional outcomes of intracorporeal and extracorporeal anastomosis after PPG. METHODS: A retrospective analysis was performed on 90 patients for cT1N0 gastric cancer who underwent laparoscopic pylorus preserving gastrectomy from January 2015 to June 2017 at the OOO, Korea; 38 patients underwent intracorporeal (TLPPG) and 52 underwent extracorporeal (LAPPG) anastomosis. The postoperative oncological, surgical, and functional outcomes were compared between the two groups. In order to compare the outcomes in obese patients, the postoperative and functional outcomes in patients with a BMI of ≥25, and in those with abdominal wall thickness measuring ≥28 mm, were evaluated. RESULTS: The TLPPG group showed a significantly reduced wound size (4 cm (3~4) vs 5 cm (5~6), p<0.001) and had fewer wound complaints than the LAPPG group (0.0% vs 15.4%, p=0.01). Postoperative complications were not significantly different between the two groups. In the BMI ≥25 subgroup, the first flatus time after operation was shorter in the TLPPG group (2.9±0.5 vs 3.5±0.8 days, p=0.04). CONCLUSION: The study demonstrates that both TLPPG and LAPPG are safe and feasible, and that there is a potential benefit for obese patients.

Successful Treatment of Neonatal Pylorospasm with Intravenous Atropine

Pylorospasm is a cause of delayed gastric emptying in young infants. As in patients with hypertrophic pyloric stenosis, most pylorospasm patients present with projectile vomiting. However, unlike that in case of hypertrophic pyloric stenosis, no persistent pyloric stenotic lesions are present. As such, follow-up using serial gastrointestinal fluoroscopy or ultrasonography can be helpful in diagnosing patients with clinical signs of gastroparesis. Most cases can be treated conservatively, but some patients require pharmacologic treatment. Antispasmodics have been proposed as a treatment for pylorospasm, but their use in neonates and infants has rarely been reported. Herein, we present a case of pylorospasm diagnosed in the neonatal period and successfully treated with intravenous atropine.

Laparoscopic versus open pylorus-preserving pancreatoduodenectomy. The first meta-analyse of retrospective matched cases

Abstract Purpose: To compare the safety, feasibility, and short-term clinical benefits of laparoscopic pylorus-preserving pancreaticoduodenectomy (L-PPPD) to open pylorus-preserving pancreaticoduodenectomy (O-PPPD) through retrospective matched cases. Methods: Web of Science, Cochrane, PubMed, CNKI were searched systematically identify studies published between January and December 2017 comparing L-PPPD to O-PPPD. The meta-analysis was performed by using Review Manager 5.3. Results: Two studies matched the selection criteria, including 108 (50%) cases of laparoscopic pylorus-preserving pancreaticoduodenectomy and 108(50%) cases of open pylorus-preserving pancreaticoduodenectomy. None of the included studies were randomized, which were both retrospective matched cases. There was no difference in the incidence of postoperative pancreatic fistula, blood loss, diet start and lymph nodes. However, L-PPPD has a shorter hospital stay (p=0.0003) and O-PPPD has a shorter operative time (p=0.02) and tend to decrease the delayed gastric emptying. Conclusions: The perioperative safety of laparoscopic surgery, which also has advantages of minimal invasion and shorter hospital stay, is comparable to that of open surgery. Laparoscopic surgery could be operated if the patients matched the indication and operation difficulty is not so great. However, blind pursuits of L-PPPD should be restrained because there is no essential difference between these two in terms of feasibility, safety and short-term complication.

Alleviation of ascorbic acid-induced gastric high acidity by calcium ascorbate in vitro and in vivo

Ascorbic acid is one of the most well-known nutritional supplement and antioxidant found in fruits and vegetables. Calcium ascorbate has been developed to mitigate the gastric irritation caused by the acidity of ascorbic acid. The aim of this study was to compare calcium ascorbate and ascorbic acid, focusing on their antioxidant activity and effects on gastric juice pH, total acid output, and pepsin secretion in an in vivo rat model, as well as pharmacokinetic parameters. Calcium ascorbate and ascorbic acid had similar antioxidant activity. However, the gastric fluid pH was increased by calcium ascorbate, whereas total acid output was increased by ascorbic acid. In the rat pylorus ligation-induced ulcer model, calcium ascorbate increased the gastric fluid pH without changing the total acid output. Administration of calcium ascorbate to rats given a single oral dose of 100 mg/kg as ascorbic acid resulted in higher plasma concentrations than that from ascorbic acid alone. The area under the curve (AUC) values of calcium ascorbate were 1.5-fold higher than those of ascorbic acid, and the C(max) value of calcium ascorbate (91.0 ng/ml) was higher than that of ascorbic acid (74.8 ng/ml). However, their T(max) values were similar. Thus, although calcium ascorbate showed equivalent antioxidant activity to ascorbic acid, it could attenuate the gastric high acidity caused by ascorbic acid, making it suitable for consideration of use to improve the side effects of ascorbic acid. Furthermore, calcium ascorbate could be an appropriate antioxidant substrate, with increased oral bioavailability, for patients with gastrointestinal disorders.

Fish-Mouth Closure of the Pancreatic Stump and Parachuting of the Pancreatic End with Double U Trans-Pancreatic Sutures for Pancreatico-Jejunostomy

PURPOSE: Leakage of pancreatico-jejunal anastomosis (PJ) remains the primary cause of morbidity and mortality after Whipple's operation. To reduce the occurrence thereof, the present author recently began to apply a modification of the Blumgart method of anastomosis after Whipple's operation (hereinafter referred to as Lee's method), with very good results. MATERIALS AND METHODS: The modified method and technique utilizes fish-mouth closure of a beveled pancreatic stump and parachuting of the pancreatic end with double U trans-pancreatic sutures (symmetric horizontal mattress-type sutures between the full thickness of the pancreas and the jejunal limb) after duct-to-mucosa pancreatico-jejunostomy. RESULTS: Eleven cases of pylorus preserving Whipple's operation have been performed without a clinically significant postoperative pancreatic fistula. CONCLUSION: This new method (Lee's method) may dramatically reduce the occurrence of postoperative pancreatic fistula after Whipple's operation.