Is it Beneficial to Utilize an Articulating Instrument in Single-Port Laparoscopic Gastrectomy?

Purpose@#As the number of gastric cancer survivors is increasing and their quality of life after surgery is being emphasized, single-port surgery is emerging as an alternative to conventional gastrectomy. A novel multi-degree-of-freedom (DOF) articulating device, the ArtiSential ® device (LivsMed, Seongnam, Korea), was designed to allow more intuitive and meticulous control for surgeons facing ergonomic difficulties with conventional tools. In this study, we evaluated the feasibility of this new device during single-port laparoscopic distal gastrectomy (SP-LDG) for early gastric cancer (EGC) patients. @*Materials and Methods@#Consecutive patients diagnosed with EGC who underwent SP-LDG with ArtiSential ® (LivsMed) graspers between April 2018 and August 2020 were enrolled in the study. The clinical outcomes were compared with those of a control group, in which prebent graspers (Olympus Medical Systems Corp) were used for the same procedures. @*Results@#Seventeen patients were enrolled in the ArtiSential ® group. There was no significant difference in operative time (205.4±6.0 vs. 218.1±9.9 minutes, P= 0.270) or the quality of surgery, in terms of the number of retrieved lymph nodes (49.5±3.5 vs. 45.9±4.0, P=0.473), length of hospital stay (15.4±2.0 vs. 12.4±1.3 days, P=0.588), and postoperative complications (40.0% vs. 41.2%, P=0.595), between the ArtiSential ® group and the control group. @*Conclusions@#The new multi-DOF articulating grasper is feasible and can be used as an alternative for prebent graspers during SP-LDG.

Uncut Roux-en-Y gastrojejunostomy after totally laparoscopic distal gastrectomy: Learning curve and surgical outcomes

Purpose@#Totally laparoscopic distal gastrectomy (TLDG) is now widely used for early gastric cancer patients, but the selection of a reconstruction method after TLDG is still controversial. Roux-en-Y gastrojejunostomy is increasingly used in expectation of less gastritis and alkaline reflux despite its technical difficulty. The uncut Roux-en-Y gastrojejunostomy (uRYGJ) retains the advantages of Roux-en-Y reconstruction but helps prevent Roux stasis syndrome. The present study aims to introduce a single surgeon’s experience of TLDG with uRYGJ and analyze the learning curve and surgical outcomes. @*Methods@#We retrospectively reviewed the medical records of 124 consecutive patients who underwent TLDG with uRYGJ performed by a single surgeon between July 2014 and August 2015 at Asan Medical Center. The baseline characteristics and surgical outcomes were analyzed, and the learning curve was drawn based on the power-law model. @*Results@#The mean total operative time was 165 minutes, and the average length of hospital stay was 6.6 days. Complications included two cases of duodenal stump leakage, two intra-abdominal bleeding, two intra-abdominal fluid collection, one wound problem, two anastomotic strictures, 14 ileus, and no anastomotic leakage. There were five cases of endoscopically proven reflux gastritis/esophagitis and no Roux stasis syndrome. There were five recurrences and one mortality during the follow-up period. The learning curve leveled at the 15th case. @*Conclusion@#The results of our study showed the safety and feasibility of uRYGJ, and that the technical difficulty of the procedure can be overcome with a short learning curve for experienced surgeons.

The history and prospect of laparoscopic gastric cancer surgery / 中华消化外科杂志

Gastric malignant tumor is one of the most common and fatal tumors in the world. According to data in 2012, gastric cancer ranks the fifth and third in the incidence rate and tumor related mortality rate of malignant tumors worldwide. Therefore, gastric cancer is one of the diseases that seriously endanger people′s health. Laparoscopic surgery not only minimize surgical trauma, but also reduce complications and accelerate recovery of patients. Therefore, laparoscopic surgery has gradually replaced open surgery in the field of surgery. Based on related prospective, randomized researches and literatures, development history of laparoscopic surgery of gastric cancer, and combined with author′s clinical experience and the latest insights, the authors make an investigation on the laparoscopic surgery of gastric cancer.

Risk Factors for Gallbladder Stone Formation after Gastric Cancer Surgery

PURPOSE: Although an increased incidence of gallbladder (GB) stone formation after gastrectomy has been reported, its etiology remains uncertain. The goal of this study was to explore the incidence of gallstone formation after gastrectomy in gastric cancer patients and investigate the risk factors therein.MATERIALS AND METHODS: Medical records of patients who underwent curative gastrectomy, performed by a single surgeon between August 2012 and December 2015 at the Asan Medical Center, were retrospectively reviewed. Baseline characteristics and surgical outcomes, including GB stone gallstone formation after gastrectomy, were analyzed.RESULTS: Of 561 patients included in the study, 36 presented with GB stone formation after gastrectomy for gastric cancer. The incidence of gallstone formation was 6.4%. The mean interval between gallstone formation and gastrectomy was 21.9 months. In multivariate analyses, the incidence of gallstone formation increased in patients 63 years or older, with greater than 6.2 kg weight loss in the first 6 months after the procedure, a preoperative serum total bilirubin level greater than 0.5 mg/dL, and in patients who did not receive adjuvant chemotherapy.CONCLUSIONS: This study presented risk factors for GB stone formation after gastric cancer surgery, and special attention should be afforded to patients with such risk factors.

Surgical Outcomes and Follow-Up Results of 100 Cases of Laparoscopic Total Gastrectomy Using the Overlap Method with Stapled Closure

PURPOSE: The overlap method is one of the most popular procedures for construction of an esophagojejunostomy and its common entry is usually closed with sutures. This study aimed to report long-term complications and surgical outcomes of the overlap method with stapled closure (OMSC), to compare them with those of laparoscopy-assisted total gastrectomy (LATG), and to analyze a learning curve.METHODS: Between January 2015 and August 2017, 100 consecutive patients underwent laparoscopic total gastrectomy with OMSC for gastric cancer and the patients' medical records were reviewed. Their clinicopathologic characteristics, surgical outcomes, and long-term complications were investigated and compared with those of the LATG group. A learning curve of OMSC was analyzed using the Exponentially Weighted Moving Average chart.RESULTS: The overall duration of surgery was shorter in the LATG group; however, there was no difference in patients with early gastric cancer. Hospital admission was shorter and the pain scale was lower in the OMSC group. There was no difference in the number of harvested lymph nodes, date of flatus, or incidence of postoperative morbidity. Both groups showed no duodenal stump leakage, anastomosis-related complications, recurrence, or mortality during the follow-up period. Petersen hernia was a notable long-term event following OMSC compared with LATG. At least 27 cases of surgery were required to reach a plateau in terms of surgery duration for OMSC.CONCLUSION: OMSC is a safe option for the treatment of gastric cancer and has favorable long-term results and surgical outcomes. Closure of mesenteric defects and Petersen space should be considered.

Clinical outcomes of staged bilateral carotid endarterectomy for bilateral carotid artery stenosis

PURPOSE: This retrospective cohort study aimed to determine the clinical outcomes of staged bilateral carotid endarterectomy (CEA) for bilateral internal carotid artery (ICA) stenosis performed with a short interval between the primary and secondary CEA procedures. METHODS: In our institution, 574 consecutive patients underwent CEA between September 2007 and August 2014. Bilateral significant ICA stenosis was identified in 43 patients (7.5%) who underwent staged bilateral CEA within 30 days or less. Patients with unilateral CEA and staged bilateral CEA were compared in terms of CEA outcomes. The primary endpoint was the composite of any stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 3 years after the CEA. RESULTS: Staged bilateral CEA was not associated with ipsilateral stroke (P = 0.178) during postoperative follow-up. The two groups did not differ in terms of estimated 3-year primary endpoint rates (2.8% vs. 4.7%, P = 0.456) or ipsilateral stroke-free (P = 0.225), any stroke-free (P = 0.326), or overall (P = 0.739) survival rates. CONCLUSION: Patients with bilateral significant ICA stenosis can undergo staged bilateral CEA within 30 days or less with outcomes that compare favorably with those of patients undergoing unilateral CEA.

Pilot cluster randomised controlled trial of flooring to reduce injuries from falls in wards for older people.

BACKGROUND: falls disproportionately affect older people, who are at increased risk of falls and injury. This pilot study investigates shock-absorbing flooring for fall-related injuries in wards for frail older people. METHODS: we conducted a non-blinded cluster randomised trial in eight hospitals in England between April 2010 and August 2011. Each site allocated one bay as the 'study area', which was randomised via computer to intervention (8.3-mm thick Tarkett Omnisports EXCEL) or control (2-mm standard in situ flooring). Sites had an intervention period of 1 year. Anybody admitted to the study area was eligible. The primary outcome was the fall-related injury rate. Secondary outcomes were injury severity, fall rate and adverse events. RESULTS: during the intervention period, 226 participants were recruited to each group (219 and 223 were analysed in the intervention and control group, respectively). Of 35 falls (31 fallers) in the intervention group, 22.9% were injurious, compared with 42.4% of 33 falls (22 fallers) in the control group [injury incident rate ratio (IRR) = 0.58, 95% CI = 0.18-1.91]. There were no moderate or major injuries in the intervention group and six in the control group. The fall IRR was 1.07 (95% CI = 0.64-1.81). Staff at intervention sites raised concerns about pushing equipment, documenting one pulled back. CONCLUSIONS: future research should assess shock-absorbing flooring with better 'push/pull' properties and explore increased faller risk. We estimate a future trial will need 33,480-52,840 person bed-days per arm.

Cost--utility analysis of a shock-absorbing floor intervention to prevent injuries from falls in hospital wards for older people.

BACKGROUND: hospital falls place a substantial burden on healthcare systems. There has been limited research into the use of hospital flooring as an intervention against fall-related injuries. OBJECTIVE: to assess the cost-effectiveness of shock-absorbing flooring compared with standard hospital flooring in hospital wards for older people. DESIGN: a cost-utility analysis was undertaken drawing upon data collected in a pilot cluster randomised controlled trial and the wider literature. SETTING: the trial included eight hospital sites across England. Four sites installed shock-absorbing flooring in one bay, and four maintained their standard flooring. MEASUREMENTS: falls and resulting injuries and treatment were reported by hospital staff. Data on destination of discharge were collected. Patients were followed up at 3 months and further resource use data were collected. Health-related quality of life was assessed, allowing quality-adjusted life years (QALYs) to be estimated. The incremental cost-effectiveness ratio of the shock-absorbing flooring was assessed compared with the standard hospital flooring. RESULTS: in the base case, the shock-absorbing flooring was cost saving, but generated QALY losses due to an increase in the faller rate reported in the intervention arm. Scenario analysis showed that if the shock-absorbing flooring does not increase the faller rate it is likely to represent a dominant economic strategy-generating cost savings and QALY gains. CONCLUSION: the shock-absorbing flooring intervention has the potential to be cost-effective but further research is required on whether the intervention flooring results in a higher faller rate than standard flooring.

Keloids demonstrate high-level epidermal expression of vascular endothelial growth factor.

BACKGROUND: Keloids are a major cause of morbidity, and arise after operation, injury, or cutaneous infection. Clinically, keloids differ from hypertrophic scars in that they grow beyond the original borders of the injury. Keloids occur most commonly for patients of African and Asian descent, and treatment options are multiple, indicating that there is no entirely satisfactory treatment for keloids. Angiogenesis inhibition has been shown to be effective in treatment of malignancy in both animal models and human beings. OBJECTIVE: We sought to determine whether keloids produce the potent angiogenic factor vascular endothelial growth factor (VEGF). METHODS: We performed in situ hybridization for VEGF on keloid tissue and normal skin. RESULTS: Our study demonstrated abundant production of VEGF in keloids and, surprisingly, the major source of VEGF was the overlying epidermis. CONCLUSIONS: Our results suggest that the overlying epidermis is the major source of keloid angiogenesis. These findings demonstrate that keloids are angiogenic lesions. Topical antiangiogenic therapy, directed at either down-regulating epidermal VEGF or inhibiting keratinocyte-derived VEGF activity on its endothelial receptors, may be useful in the treatment of keloids.