Clinical Characteristics of Intraoperative Cardiac Arrest During Cancer Surgery

Purpose@#Intraoperative cardiac arrest (IOCA) is rare, unpredictable, and may result in a poor outcome. The features of IOCA during cancer surgery and factors related to survival following an IOCA were examined. @*Methods@#This was a retrospective study of patients who had cancer surgery under general anesthesia between March 2009 and March 2021 (n = 84,615) to determine the number of patients who had an IOCA. Patients’ clinical information, cause of IOCA, hypoxemia during anesthesia, and the duration of hypotension and CPR were analyzed. @*Results@#A total of 22 cases of IOCA occurred during cancer surgery (overall incidence: 2.6 per 10,000 surgeries). Return of spontaneous circulation was achieved in 17 patients, but only 13 survived until discharge. There were statistically significant differences between the deceased and the survival cancer patient groups in; (1) duration of hypoxemia (survival group: 5 minutes, range: 2-18 minutes; deceased group: 60 minutes, range, 22.5-120 minutes; p = 0.019); (2) duration of hypotension (survival group: 35 minutes, range, 15-55 minutes; deceased group 160 minutes, range, 140-185 minutes; p = 0.007); and (3) total duration of CPR (survival group: 3 minutes, range: 1-15 minutes; deceased group: 40 minutes, range: 19-149 minutes; p = 0.005). @*Conclusion@#The duration of hypoxemia and hypotension prior to the onset of IOCA, as well as the duration of CPR were associated with the prognosis of IOCA, highlighting the need to reduce multiorgan damage caused by hypoxemia and hypotension during surgery in high-risk patients.

Clinical Outcome of Novel Reconstruction of Double Shouldering Technique after Proximal Gastrectomy

Purpose@#Various reconstruction methods have been proposed to reduce reflux after proximal gastrectomy, and we report here a double shouldering technique. The purpose of this study is to compare the novel double shouldering technique with conventional esophagogastrostomy in terms of short term and 3-year clinical outcome. @*Methods@#A retrospective observational case control study was performed on 63 patients for cT1N0 upper third gastric cancer who underwent proximal gastrectomy from January 2012 to November 2016 at the National Cancer Center, Korea. There were 26 patients with conventional esophagogastrostomy, and 37 patients with novel double shouldering technique. The primary outcome was endoscopic reflux esophagitis findings one and three year after surgery according to Los Angeles classification. Secondary outcomes were short term surgical outcome and reflux symptom. @*Results@#There was no significant difference in reflux esophagitis on endoscopic findings at 1 and 3 years after surgery between the two group. The double shouldering (DS) technique group showed significantly better postoperative outcomes with bile reflux at one and three years via endoscopic findings versus conventional esophagogastrostomy (CEG). Operative time and hospital stay were significantly shorter in the CEG group than the DS group. There was no significant difference in terms of reflux symptoms and complications. @*Conclusion@#This novel DS technique is a reconstruction method for use after proximal gastrectomy. It did not show a significant clinical benefit. Development of surgical techniques and further study is needed to identify the optimal reconstruction method after proximal gastrectomy.

Spade-Shaped Anastomosis Following a Proximal Gastrectomy Using a Double Suture to Fix the Posterior Esophageal Wall to the Anterior Gastric Wall (SPADE Operation): Case-Control Study of Early Outcomes

PURPOSE: Proximal gastrectomy (PG) is a function-preserving surgery in cases of proximally located early-stage gastric cancer. Because gastroesophageal reflux is a major pitfall of this operation, we devised a modified esophagogastrostomy (EG) anastomosis to fix the distal part of the posterior esophageal wall to the proximal part of the anterior stomach wall to produce an anti-reflux mechanism; we named this the SPADE operation. This study aimed to show demonstrate the clinical outcomes of the SPADE operation and compare them to those of previous PG cases.MATERIALS AND METHODS: Case details of 56 patients who underwent PG between January 2012 and March 2018 were retrospectively reviewed: 30 underwent conventional esophagogastrostomy (CEG) anastomosis using a circular stapler, while 26 underwent the SPADE operation. Early postoperative clinical outcome-related reflux symptoms, endoscopic findings, and postoperative complications were compared in this case–control study.RESULTS: Follow-up endoscopy showed more frequent reflux esophagitis cases in the CEG group than in the SPADE group (30% vs. 15.3%, P=0.19). Similarly, bile reflux (26.7% vs. 7.7%, P=0.08) and residual food (P=0.01) cases occurred more frequently in the CEG group than in the SPADE group. In the CEG group, 13 patients (43.3%) had mild reflux symptoms, while 3 patients (10%) had severe reflux symptoms. In the SPADE group, 3 patients (11.5%) had mild reflux symptoms, while 1 had severe reflux symptoms (absolute difference, 31.8%; 95% confidence interval, 1.11–29.64; P=0.01).CONCLUSIONS: A novel modified EG, the SPADE operation, has the potential to decrease gastroesophageal reflux following a PG.

Omental Free-Shaped Flap Reinforcement on Anastomosis and Dissected Area (OFFROAD) Following Reconstruction after Gastrectomy: A Retrospective Case-Control Study

Purpose@#We devised omental free-shaped flap reinforcement on anastomosis and dissected area (OFFROAD) following reconstruction after gastrectomy. This study aimed to evaluate its safety and early clinical outcomes. @*Methods@#One hundred fifty-six patients who underwent totally laparoscopic distal gastrectomy with delta anastomosis from July 2016 to April 2018 were divided into the OFFROAD group (80 patients) and non-OFFROAD group (76 patients). Differences in short-term operative outcomes and surgical complications were compared between the groups. All patients’ inflammatory marker levels were measured to monitor flap necrotic change and inflammatory reactions. The clinical features of both groups in terms of anastomotic leakage were transcribed. @*Results@#Pain score in postoperative day1 was significantly lower in OFFROAD group. The serum WBC count on POD 1 was significantly lower in OG than in NOG. The mean duration of OFFROAD was shorter than five minutes. There were no statistical differences in short-term outcomes and surgical complications between two groups. Anastomotic leakage occurred in three patients in each group and there was no statistical difference in incidence. However, clinical features were notable when anastomotic leakage occurs. Unlike all three patients of non-OFFROAD group manifested every features of peritonitis, each patient of OFFROAD group just manifested only one of the three. @*Conclusion@#This study showed the safety and feasibility of OFFROAD procedure. It might mitigate septic complications when there is an anastomotic leakage. Additional large-scale study is needed to assess the versatile usefulness of OFFROAD aside from its role as a physical barrier.

Clinical Outcome of Novel Reconstruction of Double Shouldering Technique after Proximal Gastrectomy

Purpose@#Various reconstruction methods have been proposed to reduce reflux after proximal gastrectomy, and we report here a double shouldering technique. The purpose of this study is to compare the novel double shouldering technique with conventional esophagogastrostomy in terms of short term and 3-year clinical outcome. @*Methods@#A retrospective observational case control study was performed on 63 patients for cT1N0 upper third gastric cancer who underwent proximal gastrectomy from January 2012 to November 2016 at the National Cancer Center, Korea. There were 26 patients with conventional esophagogastrostomy, and 37 patients with novel double shouldering technique. The primary outcome was endoscopic reflux esophagitis findings one and three year after surgery according to Los Angeles classification. Secondary outcomes were short term surgical outcome and reflux symptom. @*Results@#There was no significant difference in reflux esophagitis on endoscopic findings at 1 and 3 years after surgery between the two group. The double shouldering (DS) technique group showed significantly better postoperative outcomes with bile reflux at one and three years via endoscopic findings versus conventional esophagogastrostomy (CEG). Operative time and hospital stay were significantly shorter in the CEG group than the DS group. There was no significant difference in terms of reflux symptoms and complications. @*Conclusion@#This novel DS technique is a reconstruction method for use after proximal gastrectomy. It did not show a significant clinical benefit. Development of surgical techniques and further study is needed to identify the optimal reconstruction method after proximal gastrectomy.

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.

A Case of Extramedullary Hematopoiesis Associated with Congenital Dyserythropoietic Anemia / 소아외과

It has been known that extramedullary hematopoiesis occurring after birth can be developed in various diseases, and it is often found in hematologic diseases. Among these, congenital dyserythropoietic anemia is a rare disease characterized with increase of ineffective hematopoiesis and morphological abnormalities of erythroblasts. In congenital dyserythropoietic anemia, extramedullary hematopoiesis is very rare and only a few cases have been reported. Although treatment is not required if there is no symptom in extramedullary hematopoiesis, surgery or radiation therapy is effective in case that there is symptom or unresponsive anemia despite blood transfusion. This case report is about surgical treatment for extramedullary hematopoiesis in 23-year-old patients diagnosed of congenital dyserythropoietic anemia.

Video of Totally Laparoscopic Modified Esophagogastrostomy Using a Spade Shaped Anastomosis Following Proximal Gastrectomy (SPADE Operation)

Proximal gastrectomy (PG) has been tried as a function-preserving surgery for management of early upper gastric cancer. However, Reflux symptoms and stricture limit its applicability. We designed an anastomosis between the distal part of the posterior esophageal wall and the proximal part of the anterior wall of the stomach to make an anti-reflux mechanism. We named it the SPADE operation owing to its spade-like shape and because it is an acronym for a spade-shaped esophagogastrostomy after PG, which creates a partially duplicated esophagogastric wall. This video illustrates the case of a 74-year-old man diagnosed with early gastric cancer in the high body of the stomach along the greater curvature. We performed a totally laparoscopic proximal gastrectomy and a SPADE operation. He was discharged on the 7th postoperative day with an uneventful postoperative course and resumption of diet without reflux symptoms.