Laparoscopic management of hypertrophic hypersecretory gastropathy with protein loss: a case report.

Hypertrophic hypersecretory gastropathy with protein loss (HHGP) is a rare form of acquired gastropathy characterized by giant gastric rugal folds and hypoalbuminemia. It is often misdiagnosed as Ménétrier's disease. We report the case of a 45-year-old man with HHGP who presented with nausea and anorexia. The patient had no underlying disease and was not on medication. Esophagogastroduodenoscopy and CT showed a thickening of the gastric folds in the stomach. As cancer cells were not detected on endoscopic biopsies, the patient was diagnosed with Ménétrier's disease. He was managed with a high-protein diet and annual follow-up by esophagogastroduodenoscopy. Five years after the diagnosis, the patient underwent laparoscopy-assisted total gastrectomy for refractory abdominal pain, diarrhea, and protein loss. A pathological diagnosis of HHGP was made and he was discharged without any surgical complications. The patient was relieved of anorexia, abdominal pain, and diarrhea. Laparoscopy-assisted total gastrectomy could be regarded as a treatment option for HHGP.

Simultaneous ventral hernia repair in bariatric surgery.

BACKGROUND: Obesity is a significant risk factor in abdominal hernia occurrence and recurrence. In patients having bariatric surgery, there are no clear guidelines as to whether repair should be done simultaneously, especially if procedures involve division or resection of part of the gastrointestinal tract. METHODS: A retrospective case series review over a 6-year period to December 2012 from a prospective database was conducted. As per existing practice for bariatric procedures, patients were followed up indefinitely. Short- and long-term outcomes were analysed. RESULTS: Forty-five patients underwent combined laparoscopic bariatric surgery and abdominal wall hernia repair. Of these, 36 had resection procedures (gastric bypass or sleeve gastrectomy) and 9 had non-resection procedures (gastric banding). The mean operative time was 151 min and the mean length of stay was 3 days. Two patients developed post-operative mesh seroma infections. To date, there have been no mesh removals or recurrent hernias. There was no mortality in this series. DISCUSSION: This study demonstrated a low rate of mesh infection (4.44%) at a median follow-up of 13 months, even when a resectional procedure was performed (5.56%). These results suggest the possible viability and reasonable short-/long-term outcomes of simultaneous laparoscopic abdominal wall hernia repair during bariatric surgical procedures, even if the surgery involved division or resection of part of the gastrointestinal tract. This topic is an area of clinical research that warrants further study.

Laparoscopy-assisted pylorus-preserving gastrectomy is better than laparoscopy-assisted distal gastrectomy for middle-third early gastric cancer.

OBJECTIVE: The purpose of this study is to compare the surgical, oncologic safety and the nutritional, functional benefit of laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy (LADG) for middle-third early gastric cancers (EGC). BACKGROUND: Of those patients with middle-third EGC, it is still difficult to determine which procedure is better between LADG and LAPPG despite alleged advantages of LAPPG. METHODS: For middle-third EGC, a retrospective analysis was performed comparing those who underwent LADG and those who underwent LAPPG. To evaluate surgical and oncologic safety, clinicopathologic differences including the postoperative morbidity, the pattern of lymph node metastasis and recurrence were analyzed. Postoperative protein, albumin, quantification of abdominal fat area using abdomen computed tomography, and the incidence of postoperative gallstone were compared for the evaluation of functional advantages. RESULTS: The overall postoperative morbidity rate was similar between LADG (n = 176) and LAPPG (n = 116). Delayed gastric emptying was less frequent in LADG than in LAPPG (1.7% vs 7.8%); however, the rates of all the other complications were significantly higher in LADG than in LAPPG (17.0% vs 7.8%). The number of examined lymph nodes and metastatic lymph nodes at each lymph node station was not significantly different and 3-year recurrence-free survival rates were also similar between LADG and LAPPG (98.8% vs 98.2%). Decreases in serum protein and albumin in postoperative 1 to 6 months and abdominal fat area in postoperative 1 year were significantly greater in LADG than in LAPPG. The 3-year cumulative incidence of gallstone was significantly higher in LADG than in LAPPG (6.5% vs 0.0%). CONCLUSIONS: For middle-third EGC, LAPPG can be considered as a better treatment option than LADG in terms of nutritional advantage and lower incidence of gallstone.

Outcomes of minimally invasive surgery for early gastric cancer are comparable with those for open surgery: analysis of 1,013 minimally invasive surgeries at a single institution.

BACKGROUND: This study aimed to compare the short- and long-term results of minimally invasive surgery (MIS) and open surgery for primary early gastric cancer (EGC) at a single high-volume institution. METHODS: The clinicopathologic and survival data of primary gastric cancer patients who underwent a minimally invasive radical gastrectomy at Seoul National University Hospital from December 2003 to January 2012 were retrospectively analyzed. For comparison of short-term outcomes, the data for 1,112 patients who underwent a radical open gastrectomy from 2007 to 2011 were collected. For long-term outcome analysis, the data for 962 patients who underwent a radical open gastrectomy from 2004 to 2006 were collected. Because the application of MIS was limited to suspected EGC, the control groups were similarly limited to patients deemed to have EGC as shown by preoperative endoscopy, endoscopic ultrasound, or both. RESULTS: The review of our database identified 1,013 patients who had undergone MIS for gastric cancer. In the short-term outcome analysis, the MIS group showed statistically better results than the open surgery group in terms of postoperative hospital stay (8.7 vs. 11.3 days; p < 0.001), estimated blood loss (75.4 vs. 142.3 ml; p < 0.001), and overall complication rate (17.5 vs. 24.4 %; p < 0.001). In the subset analysis of total gastrectomy, the local complication rate was much higher in the MIS group than in the open surgery group. Both uni- and multivariate analyses showed that not only the surgical approach but also age, chronic liver disease, chronic renal disease, and additional organ resection had significant effects on complications. In the long-term outcome analysis, the two groups showed comparable disease-free survival rates. CONCLUSIONS: The use of MIS for EGC showed a shorter operation time, a shorter postoperative hospital stay, and a lower overall complication rate than open surgery but a comparable disease-free survival rate. Total gastrectomy in the MIS group was associated with a higher complication rate than in the open group. Therefore, a new stable surgical technique needs to be established.

Esophageal dysmotility after laparoscopic gastric band surgery.

BACKGROUND: The effect of the laparoscopic adjustable gastric band (LAGB) on the esophagus has been the subject of few studies despite recognition of its clinical importance. The aim of this study was to investigate the frequency and clinical effect of esophageal dysmotility and dilatation after LAGB. METHODS: We undertook a retrospective analysis of 50 consecutive patients with no dysmotility on perioperative video contrast swallow who underwent primary LAGB operation. All patients had serial focused postoperative contrast studies for band adjustments at least 6 months post-LAGB. Clinical and radiological outcomes were assessed. RESULTS: Median follow-up time was 18 months (range 7-39 months), and the median number of contrast swallows per patient was 5. The mean excess weight loss (EWL) overall was 47 % (standard deviation (SD) 22.3). Radiological abnormalities were recorded in 17 patients (34 %, 95 % confidence interval (CI) 21-49 %), of whom 15 had radiological dysmotility and 7 had esophageal dilatation (five patients had both dysmotility and dilatation). Of these 17 patients, six (35 %) developed significant symptoms of dysphagia, gastroesophageal reflux disease (GERD) or regurgitation requiring fluid removal. In comparison, 12 of 33 (36 %) patients without radiological abnormalities developed symptoms requiring fluid removal (p = 1.00). Patients with radiological abnormalities were significantly older than those without these abnormalities. Symptoms were alleviated by removing fluid in most patients. CONCLUSIONS: The LAGB operation results in the development of radiological esophageal dysmotility in a significant proportion of patients. It is not clear if these changes are associated with an increased risk of significant symptoms. Fluid removal can reverse these abnormalities and their associated symptoms.

Stable purse-string suturing using an anterior esophagotomy for reconstruction with a circular stapler during laparoscopic total gastrectomy.

INTRODUCTION: During a laparoscopic total gastrectomy, the combined process of purse-string suture placement and anvil insertion of a circular stapler is one of the most difficult steps in the reconstruction. We have developed a stable and reliable technique in which purse-string suture placement and anvil insertion using anterior esophagotomy precede complete transection of the esophagus. METHODS: The procedure involves tying the distal esophagus, insufflating the esophagus via a nasogastric tube, anterior wall purse-string suture, anterior esophagotomy, posterior wall purse-string suture, anvil insertion, fastening purse-string suture, and transecting the esophagus. The technique has been employed in nine patients since April 2011. RESULTS: Eight of the nine gastrectomies were for patients with stage IA early gastric cancer and one was for a patient with medically intractable bleeding from multiple polyps. Three were men and six were women. Average BMI was 25.2 ± 5.3 (range, 16.3-33.9). Mean operation time was 276.2 ± 56.3 min (range, 215.0-395.0 min) and the mean duration for anvil insertion was 29.8 ± 7.0 min (range, 23.0-46.0 min). There were no intraoperative or postoperative anastomosis-related complications or mortality. CONCLUSION: Our method of anvil insertion of a circular stapler can be a good option for safe and reliable esophagojejunostomy during a laparoscopic total gastrectomy.