Convenience of Adding a Needle Grasper in Single-Incision Laparoscopic Distal Gastrectomy With Billroth I Anastomosis for Clinical Early Gastric Cancer.

PURPOSE: To overcome the technical difficulties of single-incision laparoscopic distal gastrectomy (SILDG), needle grasper (Endo ReliefTM)-assisted SILDG (NASILDG) was developed. Here, we compared the operative convenience and postoperative outcomes between SILDG and NASILDG. MATERIALS AND METHODS: A needle grasper was inserted into the right upper abdomen and used in the NASILDG. We retrospectively reviewed patients who underwent D1 + dissection and delta-shaped Billroth I anastomosis with SILDG or NASILDG performed by a single surgeon between September 2015 and August 2018. RESULTS: The SILDG (male, 50.0%) and NASILDG (male, 60.0%) groups included 10 and 15 patients, respectively. The operative time without combined operation and anastomosis was significantly shorter in the NASILDG group. Early complications and scar characteristics were not significantly different between the two groups. CONCLUSIONS: By adding a needle grasper, SILDG became more convenient without decreasing cosmetic results. NASILDG could be a recommended method to reduce the technical difficulty of SILDG.

Risk factors and clinical outcomes of postgastrectomy sarcopenia newly developed after curative resection for gastric cancer.

ABSTRACT: This study aimed to investigate the risk factors and clinical impact of newly developed sarcopenia after surgical resection on the prognosis of patients undergoing curative gastrectomy for gastric cancer (GC).The clinicopathological data of 573 consecutive patients with GC who underwent curative gastrectomy were reviewed. Their skeletal muscle mass and abdominal fat volume were measured using abdominal computed tomography.Forty six of them (8.0%) were diagnosed with preoperative sarcopenia. Among the 527 patients without sarcopenia, 57 (10.8%) were diagnosed with postgastrectomy sarcopenia newly developed 1 year after curative gastrectomy. Female sex, weight loss, proximal location of the tumor and differentiated tumor were significant risk factors of postgastectomy sarcopenia newly developed after curative gastrectomy. There was a significant difference in the 5-year overall survival among the preoperative sarcopenic, nonsarcopenic, and postgastrectomy sarcopenic groups (P = .017). Especially, there was a significant difference between nonsarcopenic and postgastrectomy sarcopenic groups (P = .009). However, there was no significant difference in the 5-year disease-free survival among the groups (P = .49).Since newly developed sarcopenia after surgical resection had an influence on the overall survival, patients with high sarcopenia risks after curative gastrectomy may require early nutritional support.

Low PARP-1 expression level is an indicator of poor prognosis in patients with stage II and III gastric cancer.

Purpose: This study aimed to investigate the relationship between DNA damage response (DDR) related protein expression and clinical outcomes of patients with stage II and III gastric cancer undergoing gastrectomy. Materials and Methods: From January 2005 to December 2017, 217 gastrectomized patients with stage II and III gastric cancer were analyzed for disease-free and overall survival (DFS and OS, respectively) based on their DDR expression status. We performed the immunohistochemical assessment of MLH1, MSH2, at-rich interaction domain 1 (ARID1A), poly adenosine diphosphate-ribose polymerase 1 (PARP-1), breast cancer susceptibility gene 1 (BRCA1), and ataxia-telangiectasia mutated (ATM) using formalin-fixed paraffin-embedded (FFPE) samples. Results: Among the 217 patients studied, the most common DDR gene whose expression was suppressed was high PARP-1 (n = 120, 55.3%), followed by ATM (n = 62, 28.6%), ARID1A (n = 45, 20.7%), MLH1 (n = 33, 15.2%), BRCA1 (n = 25, 11.5%), and MSH2 (n = 9, 4.1%). The low-expression PARP-1 group exhibited a significantly shorter 5-year OS rate than the high-expression PARP-1 group (48.1% vs. 62.7%; HR 1.519, 95% CI = 1.011-2.283, P = 0.044). In the multivariate OS analysis, TNM stage (II vs. III) (HR = 5.172, P < 0.001), low PARP-1 expression (HR = 1.697, P = 0.013) and adjuvant chemotherapy (HR = 0.382, P < 0.001) were the only significant prognostic factors. Conclusions: Low PARP-1 expression level could be an indicator of poor prognosis in gastrectomized patients with stage II and III gastric cancer.

Laparoscopic Hiatal Hernia Repair and Roux-en-Y Conversion for Refractory Duodenogastroesophageal Reflux after Billroth I Distal Gastrectomy.

Distal gastrectomy with Billroth I or II reconstruction may cause duodenogastroesophageal reflux (DGER), thereby resulting in digestive or respiratory symptoms. The mainstay of treatment is medication with proton pump inhibitors. However, these drugs may have limited effects in DGER. Laparoscopic fundoplication has been proven to be highly effective in treating gastroesophageal reflux disease (GERD), but it cannot be performed optimally for GERD that develops after gastrectomy. We report the case of a 72-year-old man with a history of distal gastrectomy and Billroth I anastomosis due to early gastric cancer. GERD due to bile reflux occurred after surgery and was refractory to medical therapy. The patient underwent Roux-en-Y conversion from Billroth I gastroduodenostomy and hiatal hernia repair with only cruroplasty. Fundoplication was not performed. His symptoms improved significantly after the surgery. Therefore, laparoscopic hiatal hernia repair and Roux-en-Y conversion can be an effective surgical procedure to treat medically refractory DGER after Billroth I gastrectomy.

Loss of skeletal muscle mass during palliative chemotherapy is a poor prognostic factor in patients with advanced gastric cancer.

Cancer causes muscle mass loss, which is associated with a poor prognosis. Chemotherapy may also reduce muscle mass. We investigated skeletal muscle mass change during palliative chemotherapy for advanced gastric cancer (AGC) and its association with treatment outcomes. We retrospectively reviewed 111 consecutive AGC patients who underwent first-line palliative chemotherapy. Skeletal muscle area was measured before and after chemotherapy at the third lumbar vertebra level using computed tomography scans. We compared skeletal muscle index (SMI), body mass index (BMI), and body weight changes to chemotherapy response and survival. The 80 male and 31 female patients' median age was 65 (range 31-87) years, and 46.8% had sarcopenia at baseline. Median pre-chemotherapy to post-chemotherapy SMI, BMI, and body weight decreases were - 4.5 cm2/m2 (- 11.3%) (P < 0.001); - 0.7 kg/m2 (- 3.2%) (P < 0.001); and - 2.0 kg (- 3.5%) (P < 0.001), respectively. Median SMI decreases for patients with objective response, stable disease, and disease progression were - 4.0 cm2/m2 (range - 20.1 ~ 9.5); - 4.5 cm2/m2 (range - 19.8 ~ 0.8); and - 3.8 cm2/m2 (range: - 17.6 ~ 0.1), respectively. Response to chemotherapy was not associated with SMI decrease (P = 0.463). In multivariable analysis, sarcopenia at baseline (HR 1.681; 95% CI 1.083-2.609, P = 0.021), decreased SMI (HR 1.620; 95% CI 1.041-2.520; P = 0.032) were significant poor prognostic factors for survival. Skeletal muscle mass decreased significantly during chemotherapy in AGC patients, but was not associated with chemotherapy response. Decreased SMI was a poor prognostic factor in AGC patients during first-line palliative chemotherapy.

Long-limb Roux-en-Y Reconstruction after Subtotal Gastrectomy to Treat Severe Diabetic Gastroparesis.

The role of surgical intervention in patients with diabetic gastroparesis is unclear. We report a case of a 37-year-old man with a history of recurrent episodes of vomiting and long-standing type 2 diabetes mellitus. Esophagogastroduodenoscopy did not reveal any findings of reflux esophagitis or obstructive lesions. A gastric emptying time scan showed prolonged gastric emptying half-time (344 minutes) indicating delayed gastric emptying. Laboratory tests revealed elevated fasting serum glucose and glycosylated hemoglobin (HbA1c, 12.9%) and normal fasting C-peptide and insulin levels. We performed Roux-en-Y reconstruction after subtotal gastrectomy to treat gastroparesis and improve glycemic control, and the patient showed complete resolution of gastrointestinal symptoms postoperatively. Barium swallow test and gastric emptying time scan performed at follow-up revealed regular progression of barium and normal gastric emptying. Three months postoperatively, his fasting serum glucose level was within normal limits without the administration of insulin or oral antidiabetic drugs with a reduced HbA1c level (6.9%). Long-limb Roux-en-Y reconstruction after subtotal gastrectomy may be useful to treat severe diabetic gastroparesis by improving gastric emptying and glycemic control.

Minimization of Wound With the Assistance of a Needle Grasper in Single-Incision Laparoscopic Appendectomy.

Background. Technical difficulties and pain from large wounds have prevented the widespread use of single-incision laparoscopic appendectomy (SILA). This study aimed to evaluate the efficacy of our newly developed needle grasper (Endo Relief)-assisted SILA (NASILA). Methods. For NASILA, about a 12-mm umbilical incision was made, and a glove port was introduced. A needle grasper was then introduced through a 2.5-mm wound on the suprapubic area. For SILA, a 2.5-cm transumbilical wound was made. The medical records of patients who underwent SILA or NASILA from June 2017 to September 2017 were retrospectively reviewed. Operative and short-term postoperative outcomes and results of telephone interviews for scars were compared. Results. A total of 49 patients in the SILA group (male: 40.8%) and 12 in the NASILA group (male: 50.0%) were included. Appendicitis status (not perforated:perforated without abscess:perforated with abscess) was significantly different between the 2 groups (SILA vs NASILA, 30:18:1 vs 4:6:2, P = .027). Additional trocars were inserted in 9 patients (18.4%) of the SILA group. The operative time was significantly shorter (43.3 ± 33.6 vs 54.1 ± 15.6 minutes, P = .012), and the highest numerical pain intensity score during the first 24 hours after surgery was significantly lower (2.4 ± 0.7 vs 3.0 ± 0.9, P = .038) in the NASILA group than in the SILA group. Hospital stay, postoperative complications, and complaint of scar were not significantly different between the 2 groups. Conclusions. NASILA was not inferior to SILA regarding cosmetic results. Operative convenience is higher in NASILA than in SILA, and the smaller surgical wound in NASILA minimizes postoperative pain.

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease.

PURPOSE: Although nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD). METHODS: Seventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD. RESULTS: There were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363). CONCLUSION: Laparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.

Analysis of lawsuit cases in the Department of Surgery in Korea.

PURPOSE: The aim of this study is to prepare medical staff in order to prevent medical malpractice litigation through analysis of litigation cases related to the department of surgery in Korea. METHODS: A total of 94 litigation cases related to the department of surgery, where a certain amount of payment was ordered to the defendant between 2005 through 2010, were analyzed. We examined time of occurrence, amount claimed and awarded in damages, plaintiff claims, and court opinion. RESULTS: An average of 3.2 years was spent from the date of the incident occurring to the end of the litigation procedures. The average amount awarded in judgments for damages was 59,708,983 ± 67,307,264 (range, 1,700,000-365,201,482) Korean won. Cases were found involving the following opinion of the court: violation of duty of care (49 cases), violation of informed consent (7 cases), violation of duty of care and informed consent (5 cases), and settlement, reconciliation, and others (32 cases). By analyzing defendants' negligence in court opinions, diagnosis (30.8%) was the most common, followed by post-operation management (27.7%). CONCLUSION: Physicians have to conduct treatment and surgery based on exact diagnosis and be careful to observe patients' conditions and symptoms after surgery. It is essential to identify the current status and characteristics of medical litigation for reducing further litigation and improving patient safety. In order to create a safe medical environment, national efforts should be made not only by individuals but also at the national level.

Laparoscopic Gastrectomy Performed by an Expert in Open Gastrectomy.

PURPOSE: Senior surgeons prefer open gastrectomy (OG), while young surgeons prefer laparoscopic gastrectomy (LG). The purpose of this study was to evaluate the surgical outcomes of LG performed by a senior surgeon who was an expert in OG during his learning period, by comparing them with LGs performed by a young surgeon. MATERIALS AND METHODS: A senior surgeon performed 50 curative gastrectomies with laparoscopy (LG-S group) from March 2015 to August 2016. A young surgeon's initial 50 LGs comprised the LG-Y group. Clinicopathological characteristics and surgical outcomes were compared between the LG-S and LG-Y groups. RESULTS: D2 lymphadenectomy was more frequently performed in the LG-S group than in the LG-Y group (P=0.029). The operation time and number of retrieved lymph nodes did not significantly differ between the 2 surgeons (P=0.258 and P=0.410, respectively). Postoperative hospital stay and postoperative complication rate were similar between 2 groups (P=0.234 and P=1.000, respectively). Similarly, significant decreases in operation time with increasing case numbers were observed for both surgeons, whereas the number of retrieved lymph nodes increased significantly in the LG-Y group but not in the LG-S group. CONCLUSIONS: The LG outcomes when performed by the senior surgeon were comparable to those when performed by the young surgeon, despite performing more extended lymphadenectomies. Senior surgeons who are experts in OG should not refrain from performing LG.

Factors predicting outcomes of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: experience at a single institution in Korea.

PURPOSE: Laparoscopic fundoplication is considered the standard surgical treatment for gastroesophageal reflux disease (GERD) in Western countries. However, some patients experience poor surgical outcomes with this procedure. The study aimed to identify the predictive factors of the surgical outcomes of laparoscopic Nissen fundoplication for the treatment of Korean GERD patients. METHODS: Sixty-one patients with GERD were treated using laparoscopic Nissen fundoplication between November 2012 and February 2015. Symptom control rates were compared according to clinical and surgical factors to identify predictive factors of successful surgical outcomes. RESULTS: Thirty-five men and 26 women were enrolled. Preoperatively, typical symptoms were present in 60 patients (98%), while atypical symptoms were present in 40 patients (66%). Postoperatively, typical symptoms were controlled in 51 of 60 patients (85.0%), while atypical symptoms were controlled in 33 of 40 patients (82.5%). Overall, at 6 months postsurgery, 54 (88.5%) reported some resolution of GERD symptoms, with 48 (78.7%) achieving complete control. Patients who exhibited a good response to proton pump inhibitor therapy had a significantly greater rate of complete symptom control (P = 0.035). CONCLUSION: Laparoscopic fundoplication is effective for controlling GERD symptoms. Response to preoperative proton pump inhibitor was a predictor of successful outcome.

A multi-center, open-label, randomized phase III trial of first-line chemotherapy with capecitabine monotherapy versus capecitabine plus oxaliplatin in elderly patients with advanced gastric cancer.

OBJECTIVES: More than half of cases of gastric cancer (GC) are diagnosed in elderly patients (≥70years). While doublet combination with fluoropyrimidines and platinum is currently considered standard first-line chemotherapy in advanced GC, the main goal of chemotherapy remains palliation. MATERIALS AND METHODS: In a multi-center phase III trial, patients with chemotherapy-naïve, metastatic GC, aged 70years or older were randomized 1:1 to receive X monotherapy (capecitabine 1000mg/m2 bid po on days one to fourteen) or XELOX (X plus oxaliplatin 110mg/m2 iv on D1). Treatment was repeated every 21days until disease progression, unacceptable toxicity, or withdrawal. Primary endpoint was overall survival (OS). RESULTS: In total, 50 patients with a median age of 77 (range, 70 to 84) were enrolled (X, n=26; XELOX, n=24). No treatment-related serious adverse events or unexpected toxicities were observed. The most frequently observed toxicities were nausea and hand-foot syndrome, with fatigue and peripheral neuropathy more common in XELOX than in X patients. Median OS was 11.1months for XELOX arm and 6.3months for X arm (HR 0.58, 95% CI 0.30-1.12, P=0.108). Although the difference was not significant, on the basis of evidence of superiority of XELOX seen in the first interim analysis, an independent data monitoring committee recommended early stopping of the trial. PFS was significantly longer (HR 0.32, 95% CI 0.17-0.61, P<0.001) with XELOX (7.1months) than with X (2.6months). CONCLUSION: Platinum-based combination chemotherapy was associated with survival benefit, as compared with X monotherapy in elderly patients with GC.

Preoperative Body Mass Index May Determine the Prognosis of Advanced Gastric Cancer.

Radical gastrectomy followed by adjuvant chemotherapy for advanced gastric cancer causes serious nutritional impairment. Our study evaluated the clinical impact of body mass index (BMI) on the long-term outcomes of advanced gastric cancer (stage II and III). We analyzed 211 cases of stage II and III gastric cancer between January 2005 and December 2010 at Chung-Ang University Hospital, Seoul, Korea. Patients were divided into four groups according to BMI: underweight, normal, overweight, and obese. In addition, we divided patients into two groups: BMI-High (BMI ≥ 23 kg/m2) vs. BMI-Low (BMI < 23 kg/m2). We assessed age, sex, tumor location, lymph node (LN) involvement, operation method, initial cancer stage, recurrence, and survival between the two groups. There was significant difference in overall survival (OS) between the underweight group and the other groups (P = 0.005). The survival of the BMI-High group was better than that of the BMI-Low group. The rate of cancer-related death in the BMI-High group was significantly lower than that in the BMI-Low group (cancer-related death: BMI-Low 27% vs. BMI-High 12.6%, P = 0.022). Our findings suggest that preoperative BMI may have an influence on the long-term outcomes of advanced gastric cancer after radical surgery and chemotherapy.

Factors Influencing Clinicians' Choice of Adjuvant S-1 versus Capecitabine plus Oxaliplatin after Curative Gastrectomy in Patients with Gastric Cancer.

Purpose: Two recent randomized, phase III trials in Asia (ACTS-GC and CLASSIC) documented the survival benefit of postoperative chemotherapy after D2 lymph node dissection in patients with gastric cancer. We sought to determine what factors influenced clinicians' choices of either S-1 or capecitabine plus oxaliplatin (CAPOX) as adjuvant therapy after curative D2 gastrectomy. Materials and Methods: We retrospectively reviewed the clinicopathologic factors and adjuvant treatments for 435 patients from nine centers in Korea who were treated with either S-1 or CAPOX adjuvant chemotherapy after undergoing curative D2 gastrectomy between January 2013 and July 2014. Results: Of the 435 patients, 204 (46.9%) were treated with S-1 and 231 (53.1%) were treated with CAPOX. The median age at diagnosis was 61 years (range, 30-88). CAPOX was prescribed more often for patients who were 65 years of age or younger than for patients who were age 65 or older (77.1% vs. 22.9%, P<0.0001). Of the patients in stage II, 121 (60.8%) were treated with S-1 and 78 (39.2%) were given CAPOX; however, of those in stage III, 83 (35.2%) received S-1 and 153 (64.8%) were treated with CAPOX (P<0.0001). Conclusions: Clinicians only preferred CAPOX for younger patients with stage III gastric cancer after curative D2 gastrectomy. However, for elderly patients, clinicians more chose S-1 regardless of the stage.

Phase II study of mFOLFOX3 (5-fluorouracil, leucovorin, oxaliplatin) as second-line treatment after gemcitabine failure in patients with unresectable/metastatic biliary tract cancer.

PURPOSE: We conducted a phase II trial of 5-fluorouracil and oxaliplatin combination chemotherapy as a second-line treatment in unresectable/metastatic biliary tract cancer patients who had failed gemcitabine-based chemotherapy. METHODS: Patients treated with gemcitabine-based palliative treatment were enrolled in this study. Patients were received modified FOLFOX3 (mFOLFOX3) consists of oxaliplatin 85 mg/m(2) (day 1) and leucovorin 30 mg (days 1, 2) followed by 5-fluorouracil 1,500 mg/m(2) (days 1, 2) every 2 weeks. RESULTS: Between March 2010 and June 2012, a total of 30 patients were enrolled in this study. Twenty-eight patients were measurable for treatment response. One achieved complete response, and one a partial response was observed. Overall response rate was 7.1% (95% confidence interval 0.9-23.5%). The median progression-free survival was 1.6 months, and the median overall survival was 4.4 months. Grade 3-4 hematologic toxicities included neutropenia (6.7%) and thrombocytopenia (3.4%). The most common non-hematologic toxicity was neuropathy (22.2%). However, the most common grade 3-4 non-hematologic toxicity was hyperbilirubinemia (5.0%). There was one treatment-related death due to neutropenic infection. CONCLUSION: mFOLFOX3 as a second-line regimen has modest effect and tolerable toxicity in unresectable/metastatic biliary tract cancer patients who have been treated previously via gemcitabine-based chemotherapy.

Aberrant loss of dickkopf-3 in gastric cancer: can it predict lymph node metastasis preoperatively?

BACKGROUND: Dickkopf-3 (DKK3) may act as a tumor suppressor as it is down-regulated in various types of cancer. This study assessed the DKK3 protein expression in gastric cancer and its potential value as a prognostic marker. METHODS: DKK3 expression was evaluated by immunohistochemistry in 158 gastric cancer samples from patients who underwent gastrectomy from 2002 to 2008. Clinicopathological parameters and survival data were analyzed. RESULTS: Loss of DKK3 expression was found in 64 of 158 (40.5%) samples, and it was associated with advanced T stage (p < 0.001), lymph node metastasis (p < 0.001), UICC TNM stage (p < 0.001), tumor location (p = 0.029), lymphovascular invasion (p = 0.035), and perineural invasion (p = 0.032). Patients without DKK3 expression in tumor cells had a significantly worse disease-free and overall survival than those with DKK3 expression (p < 0.001, and p = 0.001, respectively). TNM stage (p = 0.028 and p < 0.001, respectively) and residual tumor (p < 0.001 and p = 0.003, respectively) were independent predictors of disease-free and overall survival. Based on the preoperative clinical stage assessed by computed tomography (CT), loss of DKK3 expression was predominantly associated with worse prognosis in patients with clinically node-negative advanced gastric cancer (AGC). The combination of DKK3 expression status and CT increased the accuracy of CT staging for predicting lymph node involvement from 71.5 to 80.0% in AGC patients. CONCLUSION: Loss of DKK3 protein expression was significantly associated with poor survival in patients with gastric cancer and was strongly correlated with the TNM stage. DKK3 might be a potential biomarker of lymph node involvement that can improve the predictive power of CT.

Disappearance of Serum Methylated p16 Indicates Longer Survival in Patients with Gastric Cancer.

PURPOSE: The aim of this study was to assess clinical correlations with postoperative alteration of p16 DNA methylation, and to clarify whether postoperative changes in the serum DNA methylation status of p16 could be used as a reliable prognostic factor for gastric cancer. MATERIALS AND METHODS: Fifty-three consecutive gastric adenocarcinoma patients who underwent gastric resection (Chung-Ang University Hospital, Seoul, Korea) were included. DNA methylation of p16 was evaluated by methylation-specific polymerase chain reaction using serum DNA preoperatively and at the 10th postoperative day. The correlation between changes in methylation status and patients' prognosis was analyzed. RESULTS: p16 was methylated in 79.2% of preoperative serum DNA and in 54.7% of postoperative serum DNA, respectively. Methylation in p16 disappeared more frequently in patients who underwent standard D2 lymphadenectomy compared to those who underwent modified D1+ lymphadenectomy (P=0.016). Whereas methylation of preoperative serum DNA was not correlated with survival, patients with postoperative disappearance of p16 methylation showed longer survival than those without postoperative disappearance of p16 methylation in the patients who had gastric cancer with lymph node metastasis (P=0.042). CONCLUSIONS: Postoperative disappearance of p16 methylation could be an available prognostic factor for node-positive gastric cancer.

Pre- and intraoperative lidocaine injection for preemptive analgesics in laparoscopic gastrectomy: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: The preemptive intravenous injection of local anesthetics is known to improve postoperative pains in abdominal surgery. The aim of this study is to assess the effect of intravenous lidocaine injection and analyze the precise amount of pain by computerized patient-controlled analgesia (PCA) in patients who had undergone laparoscopy-assisted distal gastrectomy (LADG). PATIENTS AND METHODS: A double-blind placebo control study was designed, and 34 patients undergoing LADG for early gastric cancer were divided into two groups. Preoperatively and throughout the surgery, Group I received intravenous lidocaine injection, and Group C received normal saline injection for placebo. Postoperative outcomes, including the visual analog scale (VAS), the button hit counts (BHC) from PCA, and amount of fentanyl consumed, were measured. RESULTS: The demographic data were similar between the groups. The VAS score, BHC, and fentanyl consumption were lower in Group I compared with Group C (P<.05). In particular, fentanyl consumption and BHC in Group I showed a significant decrease during the first 12 hours of the study (P<.05). Postoperative adverse events showed no difference except that nausea was more frequent in the placebo group (P=.039). CONCLUSIONS: In this study, intravenous lidocaine injection showed a significant reduction in fentanyl consumption and pain during the earlier postoperative time with more favorable outcomes.

Laparoscopic reversal of Hartmann's procedure.

Reversal of Hartmann's procedure is a major surgical procedure associated with significant morbidity and mortality. Because of the difficulty of the procedure, laparoscopic reversal of Hartmann's procedure is not well established. We describe our experience with this laparoscopic procedure to assess its difficulty and safety. Five patients (4 men and 1 woman) underwent laparoscopic reversal of Hartmann's procedure (LRHP). The initial surgeries were performed to manage obstructive colorectal cancer for 4 patients, and rectovesical fistula for one patient. The procedure was laparoscopically completed for 4 patients. Conversion to open laparotomy was required for one patient, secondary to massive adhesion in lower abdomen. Transient ileostomies were made in 2 cases. Operative time ranged from 240 to 545 minutes. There was no operative mortality. LRHP can be performed safely by an experienced surgeon. However, it is still technically challenging and time consuming.

Smaller-diameter circular stapler has an advantage in Billroth I stapled anastomosis after laparoscopy-assisted distal gastrectomy.

INTRODUCTION: Billroth I gastroduodenostomy using a circular stapler is the most preferred reconstruction method after laparoscopy-assisted distal gastrectomy (LADG). The optimal stapler size for this procedure has not yet been proposed. METHODS: Sixty-five patients who underwent LADG and stapled anastomosis with a 25-mm stapler (25-mm group) and a 29-mm stapler (29-mm group) were enrolled in this study. Clinical data and gastroscopic findings at 6 and 12 months after surgery were retrospectively reviewed. RESULTS: Postoperative complications and postprandial symptoms were similar in both groups. Gastroscopically, food materials remained more frequently in the remnant stomach in the 25-mm group than in the 29-mm group at 6 months after surgery (P=.041). Gastritis and bile reflux were observed more frequently in the 29-mm group than in the 25-mm group (P=.012 and P=.015, respectively). All these differences in the gastroscopic findings between the two groups decreased at 12 months after surgery except for reflux esophagitis, which was observed more frequently in the 29-mm group (P=.002). The length of the incision was smaller in the 25-mm group than in the 29-mm group (4.39 cm versus 4.95 cm, P=.009). CONCLUSION: A small-diameter stapler is a risk factor for gastric stasis in the early postoperative period, whereas a large-diameter stapler is a risk factor for gastritis and bile reflux in the early postoperative period and for esophagitis in the late postoperative period. Thus, a small-diameter circular stapler has more advantages over a large-diameter circular stapler. It also enables a reliable anastomosis through a smaller incision and easy handling of the stapler during anastomosis.