Feasibility of Linear-Shaped Gastroduodenostomy during the Performance of Totally Robotic Distal Gastrectomy

PURPOSE: Although linear-shaped gastroduodenostomy (LSGD) was reported to be a feasible and reliable method of Billroth I anastomosis in patients undergoing totally laparoscopic distal gastrectomy (TLDG), the feasibility of LSGD for patients undergoing totally robotic distal gastrectomy (TRDG) has not been determined. This study compared the feasibility of LSGD in patients undergoing TRDG and TLDG.MATERIALS AND METHODS: ALL C: onsecutive patients who underwent LSGD after distal gastrectomy for gastric cancer between January 2009 and December 2017 were analyzed retrospectively. Propensity score matching (PSM) analysis was performed to reduce the selection bias between TRDG and TLDG. Short-term outcomes, functional outcomes, learning curve, and risk factors for postoperative complications were analyzed.RESULTS: This analysis included 414 patients, of whom 275 underwent laparoscopy and 139 underwent robotic surgery. PSM analysis showed that operation time was significantly longer (163.5 vs. 132.1 minutes, P<0.001) and postoperative hospital stay significantly shorter (6.2 vs. 7.5 days, P<0.003) in patients who underwent TRDG than in patients who underwent TLDG. Operation time was the independent risk factor for LSGD after intracorporeal gastroduodenostomy. Cumulative sum analysis showed no definitive turning point in the TRDG learning curve. Long-term endoscopic findings revealed similar results in the two groups, but bile reflux at 5 years showed significantly better improvement in the TLDG group than in the TRDG group (P=0.016).CONCLUSIONS: LSGD is feasible in TRDG, with short-term and long-term outcomes comparable to that in TLDG. LSGD may be a good option for intracorporeal Billroth I anastomosis in patients undergoing TRDG.

T-shaped Modified Delta Anastomosis as a Simple Intracorporeal Gastroduodenostomy

PURPOSE: A delta-shaped anastomosis (DA) is a widely accepted technique used for a totally laparoscopic distal gastrectomy (TLDG). Several studies have suggested various modifications to overcome the drawbacks of an original DA. We present our novel technique―a T-shaped modified delta anastomosis (TDA), and we report the early outcomes with its use in a case series. METHODS: We retrospectively reviewed the medical records of 40 patients who underwent a TLDG with TDA for early gastric cancer at OOO between February 2016 and May 2017. Perioperative outcomes, postoperative complications, and operating time were analyzed, and all data were expressed as means±standard deviation. RESULTS: We observed no major complications that required immediate postoperative intervention. Other minor and non-surgical complications were delayed gastric emptying (n=1), pneumonia (n=2), atelectasis (n=3), dumping symptom (n=1), and symptomatic bile reflux (n=1). No wound infection was reported in any patient. The total operative time was 206.5±25.4 min and the estimated blood loss was 27.8±33.5 ml. The mean time required to perform the anastomosis was 20.9±6.7 min, and the mean number of cartridges used during the operation was 4.78±0.66. CONCLUSION: We conclude that a TDA following a laparoscopic distal gastrectomy was successfully developed and showed acceptable clinical outcome.

A Novel Roux-en-Y Reconstruction Involving the Use of Two Circular Staplers after Distal Subtotal Gastrectomy for Gastric Cancer

PURPOSE: Although Roux-en-Y (R-Y) reconstruction after distal gastrectomy has several advantages, such as prevention of bile reflux into the remnant stomach, it is rarely used because of the technical difficulty. This prospective randomized clinical trial aimed to show the efficacy of a novel method of R-Y reconstruction involving the use of 2 circular staplers by comparing this novel method to Billroth-I (B-I) reconstruction. MATERIALS AND METHODS: A total of 118 patients were randomly allocated into the R-Y (59 patients) and B-I reconstruction (59 patients) groups. R-Y anastomosis was performed using two circular staplers and no hand sewing. The primary end-point of this clinical trial was the reflux of bile into the remnant stomach evaluated using endoscopic and histological findings at 6 months after surgery. RESULTS: No significant differences in clinicopathological findings were observed between the 2 groups. Although anastomosis time was significantly longer for the patients of the R-Y group (P<0.001), no difference was detected between the 2 groups in terms of the total surgery duration (P=0.112). Endoscopic findings showed a significant reduction of bile reflux in the remnant stomach in the R-Y group (P<0.001), and the histological findings showed that reflux gastritis was more significant in the B-I group than in the R-Y group (P=0.026). CONCLUSIONS: The results of this randomized controlled clinical trial showed that compared with B-I reconstruction, R-Y reconstruction using circular staplers is a safe and feasible procedure. This clinical trial study was registered at www.ClinicalTrials.gov (registration No. NCT01142271).

Laparoscopic completion total gastrectomy for remnant gastric cancer following pancreaticoduodenectomy for bile duct cancer: a case report

Laparoscopic completion total gastrectomy following pancreaticoduodenectomy (PD) has not been reported. A 73-year-old male who underwent PD 25 years ago for distal common bile duct cancer visited a surgical department for remnant gastric cancer. A previous reconstruction was performed with pancreaticojejunostomy (PJ), gastrojejunostomy and Braun anastomosis, i.e., jejunojejunostomy (JJ), between the afferent and efferent jejunal limb to prevent bile reflux into the remnant stomach. Adhesiolysis was initially performed to secure the surgical view. Lymph node dissections around the splenic artery, splenic hilum, celiac axis, left gastric artery, and common hepatic artery were performed. The PJ site was well visualized and safely preserved. Esophagojejunostomy was performed with an OrVil system. Specimen retrieval, Roux-limb preparation and JJ were performed through an extended umbilicus trocar site. A final pathologic examination revealed a 5.5-cm serosa-exposed tumor (T4a) without lymph node metastasis. The patient was discharged on postoperative day 7 without any complications.

Pylorus-Preserving Gastrectomy for Gastric Cancer

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.

A Safe and Efficacious Alternative to Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity and Type 2 Diabetes - One Anastamosis / Mini Gastric Bypass

Roux-en-y gastric bypass (RYGB) is currently used to treat obesity and metabolic syndrome. It is however technically challenging with a steep learning curve and long operating times. Laparoscopitc mini-gastric bypass (LMGB) is another surgical method that is acclaimed to achieve similar efficacy and yet safe with acceptable complication rates. We reviewedcurrent literature on LMGB on its efficacy and safety profile. Comprehensive search of available literature using a combination of key words was performed, looking out for efficacy and safety end points. Efficacy end points include excess weight loss, change in body mass index (BMI), resolution of metabolic syndrome or T2DM remission. Safety end points include mortality and morbidity rates, short and long term complications. 18 studies were selected with a total of 9392 patients. Follow up range was from 1 year to 6 years with majority of studies achieving 57%-92% excess weight loss (%EWL) within 1 year. Remission of T2DM rates were mostly more than 84%. Several studies reported better %EWL and T2DM remission when compared to SG and RYGB. Overall mortality rate was 0.152%. Morbidity rates vary from 2.7%-12.5%. Some studies reported lower mortality and complication rates in LMGB when compared to SG and RYGB. In summary, MGB is a safe and effective metabolic-bariatric procedure in treating morbid obesity and T2DM. It should be considered an alternative to standard RYGB. Risk of bile reflux, marginal ulcer and anemia needs to be explained to the patient when counselling for such procedure.

Modified intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: early experience

PURPOSE: This study presents findings on the clinical usefulness of an overlap method that is another modification for the currently well-known intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG). METHODS: We studied 42 patients diagnosed with gastric cancer who underwent TLDG between December 2011 and March 2013. Endoscopic linear staplers were used for intracorporeal anastomosis and patients were observed with endoscopic tracking six months after surgery. We retrospectively reviewed the outcome of the operation, the clinical pathological results, and the endoscopy results. RESULTS: The mean duration of the operation for 42 patients was 228.3 +/- 42.5 minutes and the mean time to complete the anastomosis was 12.18 +/- 2.3 minutes. There were no mortalities and no cases of open conversion. Following the operation, 37 patients had stage IA, 5 in stage IB, and 3 in stage II gastric cancer. Abscesses were seen in 3 patients and 5 cases of stasis during the postoperative period. Duodenoscopy 6 months after the operation showed 11 cases of gastric stasis, 28 cases of bile reflux, and 1 new case of erosive gastritis. We did not observe contraction in any of the patients. CONCLUSION: The overlap method for intracorporeal gastroduodenostomy, using an endoscopic linear stapler, can be considered a feasible and safe technique for the treatment of stomach cancer. However, a long-term comparative study is required to sufficiently evaluate our findings.

A Comparison of Outcomes of Three Reconstruction Methods after Laparoscopic Distal Gastrectomy

PURPOSE: The aim of this study was to compare the short-term surgical and long-term functional outcomes of Billroth I, Billroth II, and Roux-en-Y reconstruction after laparoscopic distal gastrectomy. MATERIALS AND METHODS: We retrospectively collected data from 697 patients who underwent laparoscopic distal gastrectomy for operable gastric cancer between January 2009 and December 2012. The patients were classified into three groups according to the reconstruction methods: Billroth I, Billroth II, and Roux-en-Y. The parameters evaluated included patient and tumor characteristics, operative details, and postoperative complications classified according to the Clavien-Dindo classification. Endoscopic findings of the remnant stomach were evaluated according to the residue, gastritis, bile (RGB) classification and the Los Angeles classification 1 year postoperatively. RESULTS: Billroth I, Billroth II, and Roux-en-Y were performed in 165 (23.7%), 371 (53.2%), and 161 patients (23.1%), respectively. Operation time was significantly shorter (173.4+/-44.7 minute, P<0.001) as was time to first flatus (2.8+/-0.8 days, P=0.009), time to first soft diet was significantly faster (4.3+/-1.0 days, P<0.001), and postoperative hospital stay was significantly shorter (7.7+/-4.0 days, P=0.004) in Billroth I in comparison to the other methods. Postoperative complications higher than Clavien-Dindo grade III occurred in 61 patients (8.8%) with no statistically significant differences between groups (P=0.797). Endoscopic findings confirmed that gastric residue, gastritis, bile reflux, and reflux esophagitis were significantly lower in Roux-en-Y (P<0.001) patients. CONCLUSIONS: Roux-en-Y reconstruction after laparoscopic distal gastrectomy for middle-third gastric cancer is beneficial in terms of long-term functional outcome, whereas Billroth I reconstruction for distal-third gastric cancer has a superior short-term surgical outcome and postoperative weight change.

The Effect of Oral Cola Ingestion for Endoscopic Inspection of Remnant Stomach: Randomized Case Control Study

BACKGROUND/AIMS: Nasogastric administration of cola for dissolution of phytobezoar was reported but the mechanism is not well understood. We aimed to evaluate the efficacy of cola ingestion for upper gastrointestinal endoscopy in patients who have had distal gastrectomy. MATERIALS AND METHODS: Patients were enrolled from July 2007 to October 2007 and all previously received subtotal gastrectomy. We conducted a randomized case-control study which the patients were randomly assigned to two groups. Group A had preparation with cola and group B had no preparation. Cola preparation group ingested about 1,500 mL of cola between 7 PM to 10 PM in the evening before the procedure. Two examiners who were blinded to the type of preparation performed the endoscopy. We assessed the degree of food residue and bile reflux by Japanese classification. RESULTS: A total of 70 patients were included. The comparison of clinical and laboratory characteristics between the two groups showed no statistically significant difference. During endoscopy, food residue was less found in group A than B, but without statistically significance (group A=12.1%, group B=21.6%, P=0.087). However, bile reflux was significantly less found in group A than B (group A=36.4%, group B=67.6%, P=0.015). Multivariate analysis, cola preparation significantly reduced food residue (OR, 0.032; P=0.001) and bile reflux (OR, 0.102; P=0.001). CONCLUSIONS: Preparation with cola in the evening before endoscopic examination may provide a good quality of preparation in patient with remnant stomach after distal gastrectomy.

Does Bile Reflux Influence the Progression of Barrett's Esophagus to Adenocarcinoma? (Gastroenterology 2013;145:1300-1311)

No abstract available.

Uncut Roux-en-Y Reconstruction after Laparoscopic Distal Gastrectomy Can Be a Favorable Method in Terms of Gastritis, Bile Reflux, and Gastric Residue

PURPOSE: Laparoscopic distal gastrectomy (LDG) is a well-established procedure for the treatment of early gastric cancer. Several reconstruction methods can be adopted after LDG according to tumor characteristics and surgeon preference. This study aimed to compare the remnant gastric functions after different reconstructions. MATERIALS AND METHODS: In total, 221 patients who underwent LDG between March 2005 and October 2013 were reviewed retrospectively. The patients were classified into four groups based on the reconstructive procedure: Billroth I (BI) anastomosis, Billroth II (BII) with Braun anastomosis, Roux-en-Y (RY) reconstruction, or uncut RY reconstruction. Patient demographics, surgical outcomes, and postoperative endoscopic findings were reviewed and compared among groups. RESULTS: Endoscopic evaluations at 11.8+/-3.8 months postoperatively showed less frequent gastritis and bile reflux in the remnant stomach in the RY group compared to the BI and BII groups. There was no significant difference in the gastric residue among the BI, BII, and RY groups. The incidence of gastritis and bile reflux in the uncut RY group was similar to that in the RY group, while residual gastric content in the uncut RY group was significantly smaller and less frequently observed than that in the RY group (5.8% versus 35.3%, P=0.010). CONCLUSIONS: RY and uncut RY reconstructions are equally superior to BI and BII with Braun anastomoses in terms of gastritis and bile reflux in the remnant stomach. Furthermore, uncut RY reconstruction showed improved stasis compared to conventional RY gastrojejunostomy. Uncut RY reconstruction can be a favorable reconstructive procedure after LDG.

Clinicopathologic Charateristics and Gallbladder Dysfunction in Patients with Endoscopic Bile Reflux / 이화의대지

OBJECTIVES: To investigate clinicopathologic findings and gallbladder (GB) function in patients with endoscopic bile reflux at outpatients clinic. METHODS: We classified endoscopic bile reflux into two groups by bile reflux index (BRI). Those who scored above 14 were the BRI (+) group, and those below 14 were the BRI (-) group. We analyzed clinical characteristics, endoscopic findings including Helicobacter pylori, GB function by DISIDA scan, and electron microscope (EM) findings of endoscopic bile reflux. And we compared clinicopathologic characteristics and GB function between two groups. RESULTS: Endoscopic bile reflux identified in 9.7% of all cases with gastrointestinal symptoms. There are cholecystectomy in 6.7%, gastrectomy in 2.7%, and GB dysfunction in 20.0%. They had prominent gastrointestinal symptoms with variable endoscopic findings. Foveolar hyperplasia is the most common pathologic finding and H. pylori colonization of the stomach was inhibited in cases of bile reflux gastritis. Bile reflux also had distinguishable ultra-structural changes identifiable by EM. BRI (+) group had more old age, GB dysfunction than BRI (-) group. Clinical symptoms and endoscopic findings did not differ between the two groups of endoscopic bile reflux. CONCLUSION: Endoscopic bile reflux was common findings with young adults (30's) at outpatients clinic. Foveolar hyperplasia is common pathologic finding. GB dysfunction were identified as significant risk factors for BRI (+) group.

Optimal Duration of Medical Treatment in Superior Mesenteric Artery Syndrome in Children

The aim of this study was to investigate the outcome, and optimal duration of medical treatment in children with superior mesenteric artery syndrome (SMAS). Eighteen children with SMAS were retrospectively studied. The data reviewed included demographics, presenting symptoms, co-morbid conditions, clinical courses, nutritional status, treatments, and outcomes. The three most common symptoms were postprandial discomfort (67.7%), abdominal pain (61.1%), and early satiety (50%). The median duration of symptoms before diagnosis was 68 days. The most common co-morbid condition was weight loss (50%), followed by growth spurt (22.2%) and bile reflux gastropathy (16.7%). Body mass index (BMI) was normal in 72.2% of the patients. Medical management was successful in 13 patients (72.2%). The median duration of treatment was 45 days. Nine patients (50%) had good outcomes without recurrence, 5 patients (27.8%) had moderate outcomes, and 4 patients (22.2%) had poor outcomes. A time limit of >6 weeks for the duration of medical management tended to be associated with worse outcomes (P=0.018). SMAS often developed in patients with normal BMI or no weight loss. Medical treatment has a high success rate, and children with SMAS should be treated medically for at least 6 weeks before surgical treatment is considered.

Gastropatía reactiva: Frecuencia en biopsias endoscópicas evaluadas en la Universidad Nacional de Colombia / Reactive gastropathy: Frequency in endoscopic biopsies evaluated at the Universidad Nacional de Colombia

La gastropatía reactiva (GR) es producida principalmente por antiinflamatorios no esteroideos (AINEs) y reflujo biliar; puede presentarse aisladamente o coexistir con otros tipos de gastritis crónica (GC). Se revisaron 5.079 informes de estudios histopatológicos de biopsias gástricas de 4.254 pacientes, 825 en seguimiento con 2 a 7 estudios. La GR correspondió a 12,8% de los diagnósticos, las GC no atrófica (GCNA) y atrófica multifocal (GCAMF) correspondieron a 63,4% y 27,3% respectivamente. La infección por Helicobacter pylori se presentó en 61,6% de casos con GCNA, 51,5% con GCAMF, 18,5% con GR (p < 0.0001); en casos con coexistencia de GR+GCNA fue 43,9% y de 40,7% para GCAMF+GR. En pacientes en seguimiento aumentaron los diagnósticos de GR: 2 estudios con 22,2%, 3 estudios con 26,7% y 4-7 estudios con 28,8%; los hallazgos histológicos de GR en estos casos posiblemente son residuales, luego de la desaparición de los infiltrados inflamatorios por el tratamiento.

Reactive gastropathy (RG) is primarily produced by non-steroid antiinflammatory drugs (NSAIDs) and bile reflux. It can occur alone or coexist with other types of chronic gastritis (CG). 5,079 histopathological reports of gastric biopsies from 4,254 patients were reviewed: 825 of them had 2 to 7 follow-up studies. 12.8% of these patients were diagnosed with GR while 63.4% were diagnosed with chronic non-atrophic gastritis (CNAG) and 27.3% were diagnosed with chronic multifocal atrophic gastritis (CMAG). Helicobacter pylori infections were found in 61.6% of the cases with CNAG, 51.5% with CMAG, and in 18.5% of cases with GR only (p <0.0001). Among patients suffering from both RG and CNAG 43.9% had H. pylori infections. 40.7% of those suffering from both CMAG and RG were infected with H. pylori. During monitoring of patients RG diagnoses increased to 22.2% in the second study, 26.7% in the third study, and 28.8% in the fourth through seventh studies. Histological findings of RG in these cases are probably residual following disappearance of inflammatory infiltrates due to treatment.

Reflujo pancreáticobiliar en pacientes con colelitiasis y sin colelitiasis: estudio comparativo / Pancreaticobiliary reflux in patients with cholelithiasis and without cholelithiasis: a comparative study

Background. Pancreaticobiliary reflux is a pathologic phenomenon occurring in patients with gallstones. However, the occurrence of pancreaticobiliary reflux has not been studied in patients without gallstones. The objective of this study was to measure the bile levels of amylase and lipase in patients without gallstones submitted to cholecystectomy as part of another surgical procedure, and to compare these values with patients submitted to cholecystectomy for gallstone disease. Patients and Methods. A prospective observational comparative study was designed. A sample of 136 consecutive patients was included. Amylase and lipase levels were measured in bile. Normal serum amylase levels at our institution are 28-100 U/L and for lipase are 13-60 U/L. There are no established normal levels for pancreatic enzymes in bile. However, we considered elevated the bile amylase and lipase levels whenever they were higher than normal plasma levels. Results. One-hundred three patients (76 percent) had gallstones and 33 (24 percent) liad healthy gallbladders without gallstones. According to normal plasma levels for amylase and lipase, these enzymes in bile were elevated in 83.5 percent patients with gallstones, compared to elevated levels of amylase in 6 percent patients and lipase in 3 percent patients without gallstones. Conclusions. Pancreaticobiliary reflux is a common phenomenon in patients with gallstones and occurs sporadically in patients without gallstones.

Introducción. El reflujo pancreáticobiliar es un fenómeno patológico que ocurre en pacientes con colelitiasis. La ocurrencia de este fenómeno no ha sido estudiada en pacientes sin colelitiasis. El presente estudio tiene por objetivo medir los niveles de amilasa y lipasa en la bilis de pacientes sin colelitiasis, colecistectomizados como parte de otro procedimiento quirúrgico y comparar estos valores con pacientes colecistectomizados por colelitiasis. Pacientes y Métodos. Se diseñó un estudio observacional y comparativo. Una muestra de 136 pacientes consecutivos fue incluida. Se midieron los niveles de amilasa y lipasa en la bilis. En nuestra institución los valores normales para amilasa son 28-100 U/L y para lipasa 13-60 U/L. No se han establecido valores normales de enzimas pancreáticas en la bilis. Para efectos del presente estudio, se consideró como elevados los niveles biliares de amilasa y lipasa cuando fueron mayores a los valores plasmáticos normales. Resultados. 103 pacientes (76 por ciento) tenían colelitiasis y 33 (24 por ciento) tenían vesículas normales sin cálculos. De acuerdo a los valores plasmáticos normales de amilasa y lipasa, estas enzimas se encontraron elevadas en 83,5 por ciento de los pacientes con colelitiasis comparados con valores elevados de amilasa en 6 por ciento en pacientes sin colelitiasis y de lipasa en 3 por ciento de estos pacientes. Conclusiones. El reflujo pancreaticobiliar es un fenómeno común en pacientes con colelitiasis y ocurre esporádicamente en pacientes sin colelitiasis.

Efficacy of Roux-en-Y Reconstruction Using Two Circular Staplers after Subtotal Gastrectomy: Results from a Pilot Study Comparing with Billroth-I Reconstruction

PURPOSE: The Roux en Y method has rarely been performed due to longer operation time and high risk of complication, despite several merits including prevention of bile reflux. We conducted a retrospective review of the result of Roux en Y reconstruction using two circular staplers after subtotal gastrectomy. MATERIALS AND METHODS: From December 2008 to May 2009, a total of 26 patients underwent Roux en Y reconstruction using two circular staplers after subtotal gastrectomy, and seventy-two patients underwent Billroth-I reconstruction. Roux en Y anastomosis was performed using two circular staplers without hand sewing anastomosis. We compared clinicopathologic features and surgical outcomes between the two groups. All patients underwent gastrofiberscopy between six and twelve months after surgery to compare the bile reflux. RESULTS: No significant differences in clinicopathologic findings were observed between the two groups, except for the rate of minimal invasive surgery (P=0.004) and cancer stage (P=0.002). No differences in the rate of morbidity (P=0.353) and admission duration (P=0.391) were observed between the two groups. Gastrofiberscopic findings showed a significant reduction of bile reflux in the remnant stomach in the Roux en Y group (P=0.019). CONCLUSIONS: When compared with Billroth-I reconstruction, Roux en Y reconstruction using the double stapler technique was found to reduce bile reflux in the remnant stomach without increasing postoperative morbidity. Based on these results, we planned to begin a randomized controlled clinical trial for comparison of Roux en Y reconstruction using this method with Billroth-I anastomosis.

Nutritional Consequences and Management After Gastrectomy / 한양의대학술지

Gastric cancer is the most common cancer and the third most common cause of cancer deaths in Korea. Gastric resection, especially for the early stages of the disease, results in an excellent survival rate, and has been the mainstay of treatment for gastric cancer patients. Due to increasing use of surveillance endoscopy, the diagnosis of gastric cancer at early stages has increased. The 5-year survival rate for early gastric cancer has now improved to better than 90%, and consequently, the population of long-term survivors after gastrectomy has also increased. Therefore, the quality of life including nutritional support has become an important concern for gastrectomized patients during long-term follow-up. Nutritional capacities after gastrectomy should be evaluated by nutritional assessment and absorption tests. Nutritional deficits are more serious after total gastrectomy than after subtotal gastrectomy. Fat malabsorption has been shown to be a significant concern in patients that have undergone total gastrectomy. Other suggested causes of malnutrition include poor oral intake, relative pancreatic insufficiency, bacterial overgrowth, and shortened intestinal transit time. Food residue and bile reflux are frequently observed in the remnant stomach during surveillance endoscopy after a distal subtotal gastrectomy due to gastric cancer. The bile reflux is often associated with remnant gastritis or esophagitis and has an influence on the quality of life following a distal subtotal gastrectomy. Reconstruction methods have not influenced the food retention phenomenon after a distal gastrectomy over long-term periods. In addition, nutritional status after gastrectomy is significantly associated with postoperative complications. In conclusion, the provision of dietary education and nutritional support is highly recommended in postoperative patients for gastric cancer.

Clinical study on the treatment of gastroesophageal reflux by acupuncture / 中国结合医学杂志

<p><b>OBJECTIVE</b>To explore the clinical efficacy and safety of acupuncture in treating gastroesophageal reflux (GER).</p><p><b>METHODS</b>Sixty patients with confirmed diagnosis of GER were randomly assigned to two groups. The 30 patients in the treatment group were treated with acupuncture at acupoints Zhongwan (CV 12), bilateral Zusanli (ST36), Sanyinjiao (SP6), and Neiguan (PC6), once a day, for 1 week as a therapeutic course, with interval of 2-3 days between courses; the 30 patients in the control group were administered orally with omeprazole 20 mg twice a day and 20 mg mosapride thrice a day. The treatment in both group lasted 6 weeks. Patients' symptoms and times of reflux attacking were recorded, the 24-h intraesophageal acid/bile reflux were monitored, and the endoscopic feature of esophageal mucous membrane was graded and scored at three time points, i.e., pre-treatment (T0), immediately after ending the treatment course (T1) and 4 weeks after it (T2). Besides, the adverse reactions were also observed.</p><p><b>RESULTS</b>Compared with those detected at T0, 24-h intraesophageal pH and bile reflux, endoscopic grading score and symptom score were all decreased significantly at T1 in both groups similarly (P<0.01), showing insignificant difference between groups (P>0.05). These indices were reversed at T2 to high level in the control group (P<0.05), but the reversion did not occur in the treatment group (P>0.05). No serious adverse reaction was found during the therapeutic period.</p><p><b>CONCLUSION</b>Acupuncture can effectively inhibit the intraesophageal acid and bile reflux in GER patients to alleviate patients' symptoms with good safety and is well accepted by patients.</p>

Pancreatic and Biliary Strictures Associated with Cholangitis and Bile Reflux Following Endoscopic Papillectomy of Ampullary Adenoma / 대한소화기내시경학회지

Ampullary adenoma is rare but clinically important because it is a premalignant lesion. Use of endoscopic gastroduodenoscopy has increased detection of adenoma of the major duodenal papilla. Endoscopic papillectomy is a promising technique to supplant surgical ampullectomy, because it is less aggressive and more stable. However, various complications include bleeding, perforation, pancreatitis and cholangitis. We describe pancreatic and biliary strictures associated with cholangitis, and bile reflux through the pancreatic duct to the minor duodenal papilla after endoscopic papillectomy. Pancreatic and biliary strictures have not been hitherto reported complications. We performed endoscopic papillary balloon dilatation, minor papilla papillotomy and inserted a drain tube through the accessory pancreatic duct.

A Comparison of Segmental Gastrectomy and Distal Gastrectomy with Billroth I Reconstruction for Early Gastric Cancer That's Developed on the Gastric Body

PURPOSE: Subtotal distal gastrectomy has been accepted as the standard treatment for early gastric cancer that's developed on the gastric body. EMR and ESD have been introduced to minimize the incidence of postgastrectomy syndrome, but these procedures can not detect lymph node metastasis and they have a risk for gastric perforation. Segmental gastrectomy has recently been applied for treating early gastric cancer, but its usefulness has not been clarified. The aim of this study was to compare segmental gastrectomy and distal gastrectomy with Billroth I reconstruction for treating early gastric cancer that's developed on the gastric body. MATERIALS AND METHODS: We performed a retrospective review of all the patients who were diagnosed as having early gastric cancer that developed on the gastric body at Chungnam National University Hospital from January 2004 through July 2007. During this period, 41 patients received segmental gastrectomy and 40 patients underwent subtotal distal gastrectomy. All the patients were studied via a biannual review of the body systems, a physical examination, endoscopy, computed tomography and the laboratory findings. RESULTS: There were no significantly differences of the clinicopathologic characteristics between the two groups. The changes of the nutritional status (Hb, TP, Alb and TC) and the body weight change were not significantly different between the 2 groups. There were significantly more residual food in the SG group than that in the SDG group (RGB classification, Residual>Grade 2), but there were no differences for epigastric discomfort (P>0.05). Esophagitis developed at a similar rate for both two groups (LA classification, >Grade A), and bile reflux was found in only one patient of each group. CONCLUSION: We expected the reduction of esophagitis and gastritis and the improvement of nutritional status according to the type of procedure. Yet the results of our study showed no significant differences between the two study groups. More patients and a longer follow up time are needed for determining the advantage sand disadvantages of segmental gastrectomy.