Effect of intracorporeal anastomosis on postoperative ileus after laparoscopic right colectomy

Purpose@#Laparoscopic right colectomy (LRC) with extracorporeal anastomosis (ECA) remains the most widely adopted technique despite mounting evidence that intracorporeal anastomosis (ICA) offers several advantages. This study aimed to compare the postoperative outcomes of ICA and ECA and to investigate the effect of ICA on postoperative ileus after LRC. @*Methods@#This retrospective study included 45 patients who underwent ICA and 63 who underwent ECA in LRC for rightsided colonic diseases between January 2015 and December 2019. @*Results@#There were no significant differences in total operation time, blood loss, total length of incisions, tolerance of diet, postoperative pain score on postoperative days 1 and 2, or length of hospital stays between the 2 groups. However, the ICA group had a significantly shorter time to first flatus passage (3.0 ± 0.9 days vs. 3.8 ± 1.9 days, P = 0.013). The rate of postoperative ileus was significantly higher in the ECA group (2.2% vs. 14.3%, P = 0.033); however, there was no significant difference in the overall morbidity within 30 days after surgery. Multivariate logistic regression analysis showed that the ECA technique (odds ratio [OR], 0.098; 95% confidence interval [CI]; 0.011–0.883, P = 0.038) and previous abdominal operation (OR, 5.269; 95% CI, 1.193–23.262; P = 0.028) were independent risk factors for postoperative ileus. @*Conclusion@#The postoperative outcomes of patients who underwent LRC with ICA or ECA were comparable, and ICA could reduce the incidence of postoperative ileus after LRC compared with ECA.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer. Materials and Methods Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity. @*Results@#The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8. Conclusion The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer. Materials and Methods Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity. @*Results@#The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8. Conclusion The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Long-term Efficacy of S-1 Monotherapy or Capecitabine Plus Oxaliplatin as Adjuvant Chemotherapy for Patients with Stage II or III Gastric Cancer after Curative Gastrectomy: a Propensity Score-Matched Multicenter Cohort Study

Purpose@#To compare long-term disease-free survival (DFS) between patients receiving tegafur/gimeracil/oteracil (S-1) or capecitabine plus oxaliplatin (CAPOX) adjuvant chemotherapy (AC) for gastric cancer (GC). @*Materials and Methods@#This retrospective multicenter observational study enrolled 983 patients who underwent curative gastrectomy with consecutive AC with S-1 or CAPOX for stage II or III GC at 27 hospitals in Korea between February 2012 and December 2013. We conducted propensity score matching to reduce selection bias. Long-term oncologic outcomes, including DFS rate over 5 years (over-5yr DFS), were analyzed postoperatively. @*Results@#The median and longest follow-up period were 59.0 and 87.6 months, respectively. DFS rate did not differ between patients who received S-1 and CAPOX for pathologic stage II (P=0.677) and stage III (P=0.899) GC. Moreover, hazard ratio (HR) for recurrence did not differ significantly between S-1 and CAPOX (reference) in stage II (HR, 1.846; 95% confidence interval [CI], 0.693–4.919; P=0.220) and stage III (HR, 0.942; 95% CI, 0.664–1.337; P=0.738) GC. After adjustment for significance in multivariate analysis, pT (4 vs. 1) (HR, 11.667; 95% CI, 1.595–85.351; P=0.016), pN stage (0 vs. 3) (HR, 2.788; 95% CI, 1.502–5.174; P=0.001), and completion of planned chemotherapy (HR, 2.213; 95% CI, 1.618–3.028; P<0.001) were determined as independent prognostic factors for DFS. @*Conclusions@#S-1 and CAPOX AC regimens did not show significant difference in over-5yr DFS after curative gastrectomy in patients with stage II or III GC. The pT, pN stage, and completion of planned chemotherapy were prognostic factors for GC recurrence.

Prognostic Value of Restaging F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography to Predict 3-Year Post-Recurrence Survival in Patients with Recurrent Gastric Cancer after Curative Resection

Objective@#The aim of this study was to investigate the prognostic value of the maximum standardized uptake value (SUVmax) measured while restaging with F-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/ CT) to predict the 3-year post-recurrence survival (PRS) in patients with recurrent gastric cancer after curative surgical resection. @*Materials and Methods@#In total, 47 patients with recurrent gastric cancer after curative resection who underwent restaging with 18F-FDG PET/CT were included. For the semiquantitative analysis, SUVmax was measured over the visually discernable 18F-FDG-avid recurrent lesions. Cox proportional-hazards regression models were used to predict the 3-year PRS. Differences in 3-year PRS were assessed with the Kaplan–Meier analysis. @*Results@#Thirty-nine of the 47 patients (83%) expired within 3 years after recurrence in the median follow-up period of 30.3 months. In the multivariate analysis, SUVmax (p = 0.012), weight loss (p = 0.025), and neutrophil count (p = 0.006) were significant prognostic factors for 3-year PRS. The Kaplan–Meier curves demonstrated significantly poor 3-year PRS in patients with SUVmax > 5.1 than in those with SUVmax ≤ 5.1 (3-year PRS rate, 3.5% vs. 38.9%, p < 0.001). @*Conclusion@#High SUVmax on restaging with 18F-FDG PET/CT is a poor prognostic factor for 3-year PRS. It may strengthen the role of 18F-FDG PET/CT in further stratifying the prognosis of recurrent gastric cancer.

Nutritional Management after Bariatric Surgery

Bariatric surgery is considered the only effective method of achieving long-term weight loss and ameliorating obesity-associated comorbidities in morbidly obese patients. However bariatric surgery is associated with risks of nutritional deficiencies and malnutrition. Therefore, postoperative nutritional follow-up and supplementation of vitamins and trace elements should be recommended. In this review, we provide essential information on nutritional complications and nutritional management after bariatric surgery.

Could Adjuvant Chemotherapy after Surgery Benefit Elderly Patients with Advanced Gastric Cancer?

PURPOSE: The aim of this study was to evaluate tolerance to adjuvant chemotherapy, and to compare survival between treatments using only surgery and using surgery with adjuvant chemotherapy, in elderly patients with advanced gastric cancer who were ≥75 years of age. MATERIALS AND METHODS: Patients ≥75 years of age who were diagnosed with pathological stage II or III gastric cancer were identified retrospectively and categorized into the surgery only and surgery with adjuvant chemotherapy groups. Clinicopathological and survival data were compared between these two groups. RESULTS: Among the 130 patients studied, 67 patients underwent curative surgery only, and 63 patients received adjuvant chemotherapy after curative surgery. In the latter group, adverse events were reported in 24 patients (38.1%). The treatments were discontinued in 19 patients (30.2%) owing to any reason. The overall 5-year survival rates of the surgery only and the surgery with adjuvant chemotherapy groups did not differ significantly (44.1% vs. 30.7%, respectively; P=0.804). Among 90 death events, deaths from recurrences of gastric cancer occurred in 42 patients. Multivariate analyses revealed that the American Society of Anesthesiologists score and the depths of tumor invasions were related to survival, and the addition of adjuvant chemotherapy after surgery did not influence survival. CONCLUSIONS: The decision for the addition of adjuvant chemotherapy for elderly patients should be taken after considering the condition of individual patients and their life expectancies.

Research Trends of Quality of Life after Gastrectomy among Gastric Cancer Patients in Korea

PURPOSE: The aim of this study was to analyze the research trends of quality of life (QOL) after gastrectomy among gastric cancer patients in Korea and to make suggestions for future studies. METHODS: A literature search was done using Pubmed, CINHAL, and Korean databases in Korean and English. RESULTS: A total of 53 studies from 1993 to 2015 were analyzed. Of 53 papers, 6 (11.3%) were doctoral dissertations and master's theses, and 47 (88.7%) were from academic journals. All of the studies (100%) used quantitative research designs. The European Organisation for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ)-C30 and EORTC QLQ-STO22 were mostly used to evaluate QOL in the studies. The main research issues were varied, in particular, the most common subjects of studies were QOL related to the evaluation of treatment methods. CONCLUSION: Further studies about QOL after gastrectomy with gastric cancer patients need to be done with various approaches such as intervention studies to improve QOL, qualitative studies, and multidisciplinary research.

Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

PURPOSE: Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY). MATERIALS AND METHODS: Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance. RESULTS: uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5+/-36.2 minutes for uDelta and 240.8+/-65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1+/-8.3 minutes vs. 38.0+/-9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2+/-1.9 days in the uDelta group and 7.2+/-0.8 days in the RY group (P=0.320). CONCLUSIONS: After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

Validation of Geriatric Nutritional Risk Index and Percent Weight Loss as a Predictor of Post-operative Complications after Gastrectomy in Elderly Patients

PURPOSE: Gastric cancer surgery is expected to increase in frequency in elderly patients aged over 65 years. The aim of this study was to validate the Geriatric Nutritional Risk Index (GNRI) and percent weight loss as a predictor of post-operative complications after gastrectomy in elderly patients. METHODS: We retrospectively collected data on elderly patients (over 65 years) who underwent gastrectomy for gastric cancer at Keimyung University Dongsan Medical Center between January 2010 and December 2012. Data included patientsocharacteristics (body mass index [BMI], underlying disease, body weight loss during 3 months before gastrectomy, American Society of Anesthesiologists [ASA] score, and stage of disease), operative characteristics (operation method, operation time, and blood loss during operation), GNRI, and post-operative complications after gastrectomy. RESULTS: A total of 321 patients were included. The patients'mean age was 72.4+/-4.7 years, and 49.5% of patients were rated as being at risk by the GNRI. There were no differences in post-operative complications by GNRI, age, sex, ASA score, BMI, serum albumin, co-morbidity, stage of disease, surgical approach, type of surgery, extent of lymph node dissection, operation time, or blood loss during surgery. However, percent weight loss during 3 months was correlated independently with post-operative complications (P<0.001). In logistic regression analysis, a 1% increase in percent weight loss was associated with a 1.102 times increase in the incidence of postoperative complications (P=0.012, 95% confidence interval 1.021~1.189). CONCLUSION: The percent weight loss during 3 months before gastrectomy could help predict post-operative complications in elderly patients.

Predictive Factors for Lymph Node Metastasis in Submucosal Gastric Cancer

PURPOSE: Lymph node metastasis is an important prognostic factor in patients with early gastric cancer. Therefore, we analyzed the predictive factors for lymph node metastasis in submucosal gastric cancer and explored the feasibility of minimally invasive surgery. METHODS: The clinicopathological features of 317 patients with submucosal gastric cancer, who underwent radical gastrectomy with lymph node dissection at Department of Surgery, Keimyung University School of Medicine from January 2003 to December 2007, were examined retrospectively. The lesions were divided into 3 layers according to the depth of submucosal invasion of the cancer cell (SM1, SM2, and SM3). We analyzed the clinicopathological variables regarding lymph node metastasis. RESULTS: Of the 317 patients, 74 patients (23.3%) had lymph node metastasis. Tumor size, histological type, Lauren classification, depth of invasion, lymphatic invasion, vascular invasion, and perineural invasion showed a positive correlation with lymph node metastasis by univariate analysis. In multivariate analysis, tumor size (> or =4 cm vs <2 cm, P=0.034 and 2~4 cm vs <2 cm, P=0.043), histological type (P=0.013), and lymphatic invasion (P=0.000) were significantly correlated with lymph node metastasis. CONCLUSION: Tumor size, histological type, and lymphatic invasion were independent risk factors for lymph node metastasis in submucosal gastric cancer. Minimally invasive surgery, such as endoscopic submucosal dissection may be applied to submucosal gastric cancer with a tumor size less than 2 cm, differentiated histological type, and no lymphatic invasion.

Interactions of Nitric Oxide and Antioxidants in Hypoxia-Reoxygenation Injury

PURPOSE: An ischemia-reperfusion injury leads to profound functional and structural alterations of vascular smooth muscle cells (VSMC). It is still not clear whether hypoxia- reoxygenation and antioxidants affect the nitric oxide (NO) synthesis of VSMC. This study tried to investigate the effects of antioxidants on NO production, inducible nitric oxide synthase (iNOS) and the expression of NFkappaB p65, during the hypoxia-reoxygenation of VSMC cultures. METHODS: The VSMCs were primarily cultured from rat aortae, and confirmed by immunoreaction with the anti- smooth muscle myosin antibody. The condition of the hypoxia was verified by measuring the PO2 and PCO2 of the culture media. The concentrations of nitrite in the culture media were measured by the Griess reaction. Western blottings for the iNOS and NFkappaB p65 proteins were performed. L-NAME was used as an NOS inhibitor. Vitamins C and E, Glutathione (GSH), lipoic acid and dihydrolipoic acid (DHLA) were used as antioxidants. RESULTS: The iNOS protein was induced in the VSMC by 24 hours of hypoxia, which increased the nitrite in the VSMC culture medium. The reoxygenation profoundly increased the iNOS protein expression and nitrite concentration. The L- NAME, vitamins C and E, GSH, lipoic acid and DHLA decreased the nitrite productions during hypoxia and the hypoxia-reoxygenation, whereas, the expressions of the iNOS and NFkappaB p65 proteins were not influenced. CONCLUSION: We concluded that hypoxia-reoxygenation induced the iNOS protein, and the subsequent production of NO in the VSMC. The antioxidants and the NOS inhibitor decreased the NO production during the hypoxia-reoxygenation, but did not affect the expressions of the iNOS and NFkappaB p65 proteins