Enhanced recovery program is safe and improves postoperative insulin resistance in gastrectomy

AIM: To assess the safety of enhanced recovery after surgery(ERAS) program in gastrectomy and influences on nutrition state and insulin-resistance. METHODS: Our ERAS program involved shortening the fasting periods and preoperative carbohydrate loading. Eighty gastrectomy patients were randomly assigned to either the conventional group(CG) or ERAS group(EG). We assessed the clinical characteristics and postoperative outcomes prospectively. The primary endpoint was noninferiority in timely discharge from the hospital within 12 d. Secondary endpoints were the incidence of aspiration at anesthesia induction, incidence of postoperative complications, health related quality of life(HRQOL) using the SF8 Health Survey questionnaire, nutrition state [e.g., albumin, transthyretin(TTR), retinal-binding protein(RBP), and transferrin(Tf)], the homeostasis model assessment-insulin resistance(HOMA-R) index, postoperative urine volume,postoperative weight change, and postoperative oral intake.RESULTS: The ERAS program was noninferior to the conventional program in achieving discharge from the hospital within 12 d(95.0% vs 92.5% respectively; 95%CI:-10.0%-16.0%). There was no significant difference in postoperative morbidity between the two groups. Adverse events such as vomiting and aspiration associated with the induction of general anesthesia were not observed. There were no significant differences with respect to postoperative urine volume, weight change, and oral intake between the two groups. EG patients with preoperative HOMA-R scores above 2.5 experienced significant attenuation of their HOMA-R scores on postoperative day 1 compared to CG patients(P = 0.014). There were no significant differences with respect to rapid turnover proteins(TTR, RBP and Tf) or HRQOL scores using the SF8 method.CONCLUSION: Applying the ERAS program to patients who undergo gastrectomy is safe, and improves insulin resistance with no deterioration in QOL.

possible role of soluble fibrin monomer complex after gastroenterological surgery

AIM To examine the role of soluble fibrin monomer complex(SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODS We collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.RESULTS A total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five(28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7(OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/ml(AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to highSFMC patients who did not.CONCLUSION The SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.

Predictive factors for body weight loss and its impact on quality of life following gastrectomy

AIM To determine the predictive factors and impact of body weight loss on postgastrectomy quality of life(QOL). METHODS We applied the newly developed integrated questionnaire postgastrectomy syndrome assessment scale-45, which consists of 45 items including those from the Short Form-8 and Gastrointestinal Symptom Rating Scale instruments, in addition to 22 newly selected items. Between July 2009 and December 2010, completed questionnaires were received from 2520 patients with curative resection at 1 year or more after having undergone one of six types of gastrectomy for Stage Ⅰ gastric cancer at one of 52 participating institutions. Of those, we analyzed 1777 eligible questionnaires from patients who underwent total gastrectomy with Roux-en-Y procedure(TGRY) or distal gastrectomy with Billroth-I(DGBI) or Roux-en-Y(DGRY) procedures. RESULTS A total of 393, 475 and 909 patients underwent TGRY, DGRY, and DGBI, respectively. The mean age of patients was 62.1 ± 9.2 years. The mean time interval between surgery and retrieval of the questionnaires was 37.0 ± 26.8 mo. On multiple regression analysis, higher preoperative body mass index, total gastrectomy, and female sex, in that order, were independent predictors of greater body weight loss after gastrectomy. There was a significant difference in the degree of weight loss(P < 0.001) among groups stratified according to preoperative body mass index(< 18.5, 18.5-25 and > 25 kg/m2). Multiple linear regression analysis identified lower postoperative body mass index, rather than greater body weight loss postoperatively, as a certain factor for worse QOL(P < 0.0001) after gastrectomy, but the influence of both such factors on QOL was relatively small(R2, 0.028-0.080).CONCLUSION While it is certainly important to maintain adequate body weight after gastrectomy, the impact of body weight loss on QOL is unexpectedly small.

Safety and Efficacy of Laparoscopy-Assisted Gastrectomy after Endoscopic Submucosal Dissection for Early Gastric Cancer: A Retrospective Report

Background: This study aimed to determine the safety and effectiveness of laparoscopy-assisted distal gastrectomy (LADG) after ESD. Methods: We reviewed patients with gastric cancer who underwent distal gastrectomy after non-curative ESD from May 2000 to July 2010, and classified them into LADG-ESD and open distal gastrectomy (ODG) after non-curative ESD (ODG-ESD). In addition, we analyzed the standard LADG (LADG-standard) during the same period. We retrospectively analyzed surgical outcomes and survival in these 3 groups. Pathological results after gastrectomy were compared between the LADG-ESD and ODG-ESD;Results: Sixty-one patients underwent distal gastrectomy after non-curative ESD. No differences in overall survival were found between the LADG-ESD and ODG-ESD. The average duration to surgery after ESD was 42.4 days. Although the average surgical duration and average length of hospital stay after surgery were longer in the LADG-ESD than in the ODG-ESD, number of LN dissections was statistically identical in these 2 groups. Operative complications in the LADG-ESD (16.0%) was higher than that in the LADG-standard (3.8% - 8.2%) but similar to that in the ODG-ESD (13.9%). Conclusion: The present study suggests that LADG contributes to the effectiveness of the treatment of choice for non-curative endoscopic resection.

Comparison of the low-density lipoprotein cholesterol target value and the preventive effect of statins in elderly patients and younger patients

ObjectiveTo 估计低密度的脂蛋白胆固醇(LDL-C ) 目标价值和 statins 的预防效果是否在调查的老、更年轻的 patients.MethodsWe 之间是不同的在早狭窄以外为周期性的局部缺血的检查从 2007 年 1 月经历了冠的 angiography 到 2016年12月的有以前的经皮的冠的干预的 304 个病人。病人们被分类进二个组：年龄 75 年(老组：n = 140 ) 并且 < 75 年(更年轻的组：n = 164 ) 。在完成的 LDL-C 水平之间的关系，发生 statins 的近来冠的事件，和有效性是 evaluated.ResultsDuring 后续， 179 个病人经历了晚冠的 revascularization。周期性的局部缺血作为急性冠的症候群(交流) 介绍发生在 83 种情况中。Kaplan-Meier 曲线分析在更年轻的组，揭示了那周期性的交流在有 LDL-C 的病人是显著地更低的 < 70 mg/dL 比在那些与 LDL-C 从 70 到 < 100 mg/dL (P = 0.035 ) ；然而，在老组这些之间没有差别(P = 0.863 ) 。相反，周期性的交流在有 LDL-C 从 70 mg/dL 到的病人是不太经常的 < 100 mg/dL 比在那些与在老组的 LDL-C 100 mg/dL (P = 0.033 ) 。Statin 使用与减少的周期性的交流被联系(P = 0.005 ) ；而且，仅仅使用 statins 是在老组的一个独立预言者(HR：0.375；P = 0.007 ) LDL-C 到的 .ConclusionsStrict 控制 < 70 mg/dL 为在更年轻的病人减少周期性的交流的发生是有效的。然而， LDL-C < 100 mg/dL 可能作为为在日本老病人的 ischemic 事件的第二等的预防的 LDL-C-lowering 治疗的目标价值足够。

Assessing optimal Roux-en-Y reconstruction technique after total gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND Following a total gastrectomy,patients suffer the most severe form of postgastrectomy syndrome.This is a significant clinical problem as it reduces quality of life(QOL).Roux-en-Y reconstruction,which is regarded as the gold standard for post-total gastrectomy reconstruction,can be performed using various techniques.Although the technique used could affect postoperative QOL,there are no previous reports regarding the same.AIM To investigate the effect of different techniques on postoperative QOL.The data was collected from the registry of the postgastrectomy syndrome assessment study(PGSAS).METHODS In the present study,we analyzed 393 total gastrectomy patients from those enrolled in PGSAS.Patients were divided into groups depending on whether antecolic or retrocolic jejunal elevation was performed,whether the Roux limb was“40 cm”,“shorter”(≤39 cm),or“longer”(≥41 cm),and whether the device used for esophageal and jejunal anastomosis was a circular or linear stapler.Subsequently,we comparatively investigated postoperative QOL of the patients.RESULTS Reconstruction route:Esophageal reflux subscale(SS)occurred significantly less frequently in patients who underwent antecolic reconstruction.Roux limb length:“Shorter”Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS.Anastomosis technique:In terms of esophagojejunostomy techniques,no differences were observed.CONCLUSION The techniques used for total gastrectomy with Roux-en-Y reconstruction significantly affected postoperative symptoms.Our results suggest that elevating the Roux limb,which is not overly long,through an antecolic route may improve patients’QOL.

俯卧位采集和CT衰减校正在CZTSPECT显像检测冠状动脉疾病中的比较

【摘要】目的带碲-锌-镉（CZT）固态探测器的核素显像仪可更好地诊断和评估胸痛患者，但其与普通γ照相机一样存在下壁和（或）下侧壁的衰减现象。在常规仰卧位采集图像的基础上加做CT衰减校正（CTAC）和俯卧位图像采集，来分析比较仰卧位显像、仰卧位＋CTAC和俯卧位显像的结果。