Is prophylactic placement of drains necessary after subtotal gastrectomy?

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery. METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups. RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）. CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.

Subtotal gastrectomy combined with chemotherapy: An effective therapy for patients with circumscribed Borrmann type Ⅳ gastric cancer

BACKGROUND Although Borrmann type Ⅳ(B-4) gastric cancer has a higher mortality rate and presents distant metastasis easily, especially peritoneal metastasis, when diagnosed, some B-4 patients were found to have no distant metastasis by preoperative detection and underwent curative surgery, which was defined as circumscribed B-4 in our study. In this study, we focused on the circumscribed B-4 patients without distant metastasis during surgery to identify factors related to prognosis and postoperative peritoneal cavity metastasis(PPCM), which is important for selecting an appropriate therapeutic strategy.AIM To identify factors related to the prognosis and PPCM of B-4 patients.METHODS A total of 117 B-4 patients who underwent gastrectomy between January 2005 and December 2012 were included in this study. Survival analysis was performed using Kaplan–Meier analysis and Cox multivariate models. Pearson correlation analyses were performed to identify the factors related to PPCM. All statistical analyses were performed using SPSS 20.0.RESULTS Lymph node status, gastrectomy type, and postoperative chemotherapy were independent prognostic factors in 117 circumscribed B-4 patients. Subtotal gastrectomy combined with chemotherapy could significantly improve the longterm survival time. Six patients who were diagnosed with pN0 and received the combination therapy had a 3-year survival rate of 100% and a median survival of 77.7 mo. Even for patients with metastatic lymph nodes(n = 13), the combination therapy also increased the 3-year overall survival rate to 57.1%. In addition, positive lymph node status was the only factor(P = 0.005) correlated with PPCM in certain B-4 patients, and chemotherapy was useful for suppressing PPCM in patients with subtotal gastrectomy but not in those with total gastrectomy.CONCLUSION Lymph node status is an independent prognostic factor for circumscribed B-4 patients. In addition, subtotal gastrectomy and postoperative chemotherapy could effectively improve prognosis and even suppress PPCM.

Role of the duodenum in regulation of plasma ghrelin levels and body mass index after subtotal gastrectomy

AIM: To investigate the role of the duodenum in the regulation of plasma ghrelin levels and body mass index (BMI), and the correlation between them after subtotal gastrectomy. METHODS: Forty-two patients with T0-1N0-1M0 gastric cancer were divided into two groups after gastrectomy according to digestive reconstruction pattern, Billroth Ⅰ group (n = 23) and Billroth Ⅱ group (n = 19). Ghrelin levels were determined with radioimmunoassay (RIA) before and on d 1, 7, 30 and 360 after gastrectomy, and BMI was also measured. RESULTS: The two groups had identical postoperative trends in ghrelin alterations during the early stage, both decreasing sharply to a nadir on d 1 (36.7% vs 35.7%), then markedly increasing on d 7 (51.0% vs 51.1%). On d 30, ghrelin levels in the Billroth Ⅰ group were slightly higher than those in the Billroth Ⅱ group. However, those of the Billroth Ⅰ group recovered to 93.6% on d 360, which approached, although lower than, the preoperative levels, and no statistically significant difference was observed. Those of the Billroth Ⅱ group recovered to only 81.6% and manifested significant discrepancy with preoperative levels (P = 0.033). Compared with preoperative levels, ghrelin levels of the two groups decreased by 6.9% and 18.4% and BMI fellby 3.3% and 6.4%, respectively. The linear regression correlations were revealed in both groups between decrease of ghrelin level and BMI (R12 = 0.297, P = 0.007; R22 = 0.559, P < 0.001).CONCLUSION: Anatomically and physiologically, the duodenum compensatively promotes ghrelin recovery and accordingly enhances BMI after gastrectomy. Regarding patients with insufficient ghrelin secretion, ghrelin is positively associated with BMI.

Beneficial effects of continual jejunal interposition after subtotal gastrectomy

Background The ideal post-gastrectomy reconstruction procedure should maintain the normal digestive function and restore intestinal transit to improve the patient quality of life. The aim of this study was to evaluate the effects of integral continual jejunal interposition after subtotal gastrectomy on the nutritional status, glucose levels, and gastric-intestinal motility. Methods The study investigated the effects of the integral continual jejunal interposition, the Billroth I and Billroth II operations, and the isolated jejunal interposition following subtotal distal gastrectomy on the blood glucose, insulin, routine blood parameters, liver function, and myoelectrical activity in Beagle dogs. Results The weights of the dogs decreased during the first post-operative weeks. Dogs in the integral continual jejunal interposition, Billroth I, and Billroth II groups gained significantly more weight by 8 weeks. The prognosis nutrition index of the dogs decreased in the first 2 post-operative weeks and increased significantly by 4 weeks in the integral continual jejunal interposition and Billroth I groups. The group with duodenal exclusion （Billroth II） had significantly higher glucose levels compared to the normal control group. The insulin curve was much higher in dogs that underwent the Billroth I, continual jejunal interposition, and isolated jejunal interposition than the Billroth II and normal groups. The frequencies of fasting and postprandial jejunal pacesetter potentials （PPs） were greater in the continual jejunal interposition and Billroth I groups than that in the isolated jejunal interposition and Billroth II groups. The percentage of aboral propagation of PPs was greater in the continual jejunal interposition group than the Billroth I, isolated jejunal interposition, and Billroth II groups. Conclusion Continual jejunal interposition after subtotal gastrectomy avoids jejunal transection, maintains the duodenal Dassaqe and food storaae baas, and reduces the influence of blood qlucose and insulin.

Clinical research on acupuncture combined with TDP for stump stomach atony after subtotal gastrectomy

Objective To verify the therapeutic methods and clinical efficacy on stump stomach atony after subtotal gastrectomy （SSASG） treated with acupuncture and TDP. Methods Fifty-three cases were divided into an observation group （23 cases） and a control group （30 cases） according to the random number table. In the observation group, acupuncture was applied in combination with TDP. The main acupoints were Zúsānlǐ （足三里 ST 36）, Píshū （脾俞 BL 20）, Wèishū （胃俞 BL 21） and Zhōngwǎn （中脘 CV 12）. The treatment was given once per day. 10 treatments made one session. Two sessions of treatment were required. In the control group, Motilium was prescribed for oral administration, 10 mg each time, three times per day, continuously for 20 days. The changes in the relevant parameters in electrogastrogram （EGG） were observed before and after treatment. The efficacy was assessed. Results The principle frequency and the waveform reaction area of EGG were improved apparently after treatment in both groups （all P0.01）, and those in the observation group were superior to those in the control group （all P0.01）. The ratio of the power after/before meal was more than 1 in the observation group after treatment and that in the control group was less than 1. The effective rate was 100.0% （23/23） in the observation group, which was superior to that of 80.0% （24/30） in the control group, presenting statistically significant difference （P0.01）. Conclusion Acupuncture in combination with TDP can effectively treat SSASG. This therapy apparently improves the gastric motility, tremendously promotes the gastrointestinal peristalsis and recovers the gastrointestinal function after operation. The efficacy of it is superior to that achieved by the oral administration of Motilium.

The influence of 3 types of subtotal gastrectomy on intragastric bacterial overgrowth in 43 cases

Detailed analysis of intragastric acidity,bacterial parameters in the gastric content including total viable bacterial count(TVBC),oral bacterial count(OBC),intestinal bacterial count(IBC) and nitrate-reducing bacterial count(NRBC) and bacterial identifications were performed on 43 samples of gastric juice obtained at endoscopy of 13 cases with Billroth Ⅰ subtotal gastrectomy(BⅠ),19 cases with Billroth Ⅱ operation(BⅡ) and 11 cases with pylorus and antroseromuscular flap preserving gastrectomy (PAFPG). Eight normal subjects were studied likewise to serve as the control.No significant difference was found in OBC among the 4 groups while the average of TVBC,IBC and NRBC and the PH value were much higher in BⅡ(P<0. 001) and BⅠ(P<0. 05) than in PAFPG and the control but no significant difference of the above mentioned parameters was found between the latter 2 groups. Large amounts of gut bacilli and enteroanaerobes such as Veillonella spp. , Bacteriodes fragilis and Clostridium spp. were identified in the gastric remnants after BⅡ or BⅠ operation but not in those after PAFPG.These findings suggest that intragastric bacterial overgrowth can exist in the hypoacidic stumps in the first 1 to 3 years aftr conventional subtotal gastrectomy especially after B Ⅱ but it cannot exist in the stumps after PAFPG since it only moderately reduces the intrastump acidity.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer:A retrospective cohort study

BACKGROUND Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory.Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.AIM To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.METHODS A retrospective analysis of clinical data and pathological characteristics(age,sex,primary site of the tumor,Lauren histotype,number of positive lymph nodes resected,number of negative lymph nodes resected,and depth of invasion as defined by the standard nomenclature)was conducted in patients with gastric cancer.For each patient we calculated the Kattan’s score.We arbitrarily divided the study population of patients into two groups based on the nomogram score(<100 points or≥100 points).Prespecified subgroups in these analyses were defined according to age(≤65 years or>65 years),and number of lymph nodes retrieved(≤35 lymph nodes or>35 lymph nodes).Uni-and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.RESULTS One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy.Perioperative mortality rate was 3.8%(7 patients);a higher mortality rate was observed in patients aged>65 years(P=0.002)and in N+patients(P=0.04).Following univariate analysis,mortality was related to a Kattan’s score≥100 points(P=0.04)and the presence of advanced gastric cancer(P=0.03).Morbidity rate was 21.0%(40 patients).Surgical complications were observed in 17 patients(9.1%).A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested(P=0.0005).CONCLUSION Mortality and morbidity rate are higher in N+and advanced gastric cancer patients.The removal of more than 35 lymph nodes does not lead to an increase in mortality.

Hand-assisted laparoscopic surgery of abdominal large visceral organs

AIM： To design a hand-assisted laparoscopic approach in an attempt to provide an option for laparoscopic resection of abdominal large viscera. METHODS： A 5-6 cm incision （for HandPort） and 2 trocars were employed. The main vessel of the target organ was taken as a ＂core＂, and all tissues around the core were taken as peripheral structures. The peripheral structures were dissected first, and the core vessels were treated last. Twenty-six patients underwent laparoscopic deroofing of the hepatic huge cysts, resection of the segments lying at the outer edge of the liver （segments 2 to 6）, splenectomy, hemicolectomy, ileocecectomy and subtotal gastrectomy with HandPort device, harmonic scalpel, or Ligasure. RESULTS： The duration of the procedure was within 2 hours. Blood loss amounted to 8-120 mL. The conversion rate was 3.8% （1/26）. All patients had uneventful postoperative courses with less pain, earlier oral intake, and faster recovery, compared with conventional surgery. CONCLUSION： This method combines the advantages of both open and laparoscopic techniques, achieving better hemostasis effect, shortening the operative time, and is beneficial to the patients.