Function-preserving gastrectomy for gastric cancer in Japan

Surgery used to be the only therapy for gastric cancer, and since its ability to cure gastric cancer was the focus of attention, less attention was paid to functionpreserving surgery in gastric cancer, though it was studied for gastroduodenal ulcer. Maki et al developed pylorus-preserving gastrectomy for gastric ulcer in 1967. At the same time, the definition of early gastric cancer(EGC) was being considered, histopathological investigations of EGC were carried out, and the validity of modified surgery was sustained. After the development of H2-blockers, the number of operations for gastroduodenal ulcers decreased, and the number of EGC patients increased simultaneously. As a result, the indications for pylorus-preserving gastrectomy for EGC in the middle third of the stomach extended, and various alterations were added. Since then, many kinds of function-preserving gastrectomies have been performed and studied in other fields of gastric cancer, and proximal gastrectomy, jejunal pouch interposition, segmental gastrectomy, and local resection have been performed. On the other hand, from the overall perspective, it can be said that endoscopic resection, which was launched at almost the same time, is the ultimate function-preserving surgery under the current circumstances. The current function-preserving gastrectomies that are often performed and studied are pylorus-preserving gastrectomy and proximal gastrectomy. The reasons for this are that these procedures that can be performed with systemic lymph node dissection, and they include three important elements:(1) reduction of the extent of gastrectomy;(2) preservation of the pylorus; and(3) preservation of the vagal nerve. In addition, these operations are more likely to be performed with a laparoscopic approach as minimally invasive surgery. Of the above-mentioned three elements, reduction of the extent of gastrectomy is the most important in our view. Therefore, we should try to reduce the extent of gastrectomy if curability of the gastric cancer can still be achieved. However, if we preserve a wider residual stomach in functionpreserving gastrectomy, we should pay attention to the development of metachronous gastric cancer.

Advancements in liver retraction techniques for laparoscopic gastrectomy

Traditionally,liver retraction for laparoscopic gastrectomy is done via manual methods,such as the placement of retractors through the accessory ports and using a Nathanson retractor.However,these techniques often posed issues including extra abdominal incisions,risk of liver injury or ischaemia,and the potential for compromised visualization.Over the years,the development of innovative liver retraction techniques has significantly improved the safety and efficacy of laparoscopic gastrectomy and similar other hiatal procedures.This editorial will comment on the article by Lin et al,and compare this to the other liver retractor techniques available for surgeons and highlight the pros and cons of each technique of liver retraction.

Comparative study of clinical efficacy of laparoscopic proximal gastrectomy with double-channel anastomosis and tubular gastroesophageal anastomosis

BACKGROUND According to statistics,the incidence of proximal gastric cancer has gradually increased in recent years,posing a serious threat to human health.Tubular gastroesophageal anastomosis and double-channel anastomosis are two relatively mature anti-reflux procedures.A comparison of these two surgical procedures,tubular gastroesophageal anastomosis and double-channel anastomosis,has rarely been reported.Therefore,this study aimed to investigate the effects of these two reconstruction methods on the quality of life of patients with proximal gastric cancer after proximal gastrectomy.AIM To compare short-term clinical results of laparoscopic proximal gastrectomy with double-channel anastomosis vs tubular gastric anastomosis.METHODS Patients who underwent proximal gastrectomy at our hospital between January 2020 and January 2023 were enrolled in this retrospective cohort study.The patients were divided into an experimental group(double-channel anastomosis,33 cases)and a control group(tubular gastric anastomosis,30 cases).Baseline characteristics,surgical data,postoperative morbidities,and postoperative nutrition were recorded.RESULTS The differences in baseline data,surgical data,and postoperative complications(20.0%vs 21.2%)were not statistically significant between the two groups.There were no statistically significant differences in the levels of postoperative nutrition indicators between the two groups of patients during the preoperative period and at 3 months postoperatively.In addition,the levels of postoperative nutrition indicators in patients in the experimental group declined significantly less at 6 months and 12 months postoperatively compared with those of the control group(P<0.05).At 12 months postoperatively,the difference in anastomotic reflux esophagitis between the two groups was statistically significant(P<0.05)with the experimental group showing less reflux esophagitis.CONCLUSION Both double-channel anastomosis and tubular gastric anastomosis after proximal gastrectomy are safe and feasible.Double-channel anastomosis has a better anti-reflux effect and is more beneficial in improving the postoperative nutritional status.

Intraluminal migration of a surgical drain near an anastomosis site after total gastrectomy:A case report

BACKGROUND Esophagojejunal anastomotic leakage(EJAL)is a severe complication following gastrectomy for gastric cancer,typically treated with drainage and nutritional support.We report a case of intraluminal drain migration near the esophagojejunal anastomosis(EJA),resulting in persistent drainage and mimicking EJAL after total gastrectomy.CASE SUMMARY A 64-year-old male underwent open total gastrectomy with Roux-en-Y reconstruction for gastric adenocarcinoma,with two silicone drains placed near the EJA.On postoperative day(POD)4,the patient developed signs of peritonitis and sepsis,necessitating surgical re-exploration abscess drainage,peritoneal lavage,and drain repositioning.A contrast swallow study on POD 18 revealed rapid filling of the abdominal drain without extraluminal contrast collection.Persistent drainage prompted an upper gastrointestinal endoscopy on POD 59,which revealed approximately 5 cm of the drain within the esophagus,with the perforation site located 2 cm distal to the intact EJA.The drain was repositioned under endoscopic guidance.A repeat contrast radiograph on POD 67 demonstrated no evidence of extraluminal contrast extravasation or filling of the abdominal drain.The patient was subsequently discharged without further incident.CONCLUSION Intraluminal drain migration is a rare complication following gastric surgery but should be considered when persistent drainage occurs.

Analysis of risk factors for dysphagia in patients after laparoscopic radical gastrectomy

BACKGROUND Gastric cancer is among the most prevalent malignancies worldwide.Despite significant advancements in chemoradiotherapy,targeted therapy,and neoadjuvant therapy,conventional surgical intervention remains the cornerstone of gastric cancer management.Improvements in surgical techniques,coupled with the use of staplers and other advanced instruments,have substantially reduced the incidence of complications and mortality following gastric cancer surgery.However,dysphagia remains a common postoperative complication.AIM To retrospectively investigate the potential factors contributing to dysphagia in patients who have undergone laparoscopic radical gastrectomy for gastric cancer and to explore effective strategies for its postoperative management.METHODS In this retrospective study,we analyzed data from patients who underwent elective laparoscopic total gastrectomy at Lihuili Hospital,Ningbo University,between January 2018 and May 2022.A total of 115 eligible postoperative patients were included.Postoperatively,patients completed questionnaires and were categorized into two groups based on their responses:The dysphagia group(Eating Assessment Tool-10 score≥3)and the non-dysphagia group(Eating Assessment Tool-10 score<3).Risk factors associated with dysphagia following total gastrectomy were assessed usingχ2 tests,Fisher’s exact tests,t-tests,Pearson correlation coefficients,and univariate and multivariate regression analyses.RESULTS Multivariate analysis further identified anastomotic style,prolonged intubation time,advanced age,and low albumin(ALB)levels as independent risk factors for postoperative dysphagia.Implementing targeted preventive measures for high-risk groups may significantly enhance postoperative quality of life.CONCLUSION Univariate analysis revealed that anastomotic style,low serum ALB levels,advanced age,and prolonged intubation time were significantly associated with postoperative dysphagia in gastric cancer patients.Multivariate analysis further identified anastomotic style,prolonged intubation time,advanced age,and low ALB levels as independent risk factors for postoperative dysphagia.Implementing targeted preventive measures for high-risk groups may significantly enhance postoperative quality of life.

Predictive value of C-reactive protein,procalcitonin,and total bilirubin levels for pancreatic fistula after gastrectomy for gastric cancer

BACKGROUND Gastric cancer is the most common malignancy of the digestive system and surgical resection is the primary treatment.Advances in surgical technology have reduced the risk of complications after radical gastrectomy;however,post-surgical pancreatic fistula remain a serious issue.These fistulas can lead to abdominal infections,anastomotic leakage,increased costs,and pain;thus,early diagnosis and prevention are crucial for a better prognosis.Currently,C-reactive protein(CRP),procalcitonin(PCT),and total bilirubin(TBil)levels are used to predict post-operative infections and anastomotic leakage.However,their predictive value for pancreatic fistula after radical gastrectomy for gastric cancer remains unclear.The present study was conducted to determine their predictive value.AIM To determine the predictive value of CRP,PCT,and TBil levels for pancreatic fistula after gastric cancer surgery.METHODS In total,158 patients who underwent radical gastrectomy for gastric cancer at our hospital between January 2019 and January 2023 were included.The patients were assigned to a pancreatic fistula group or a non-pancreatic fistula group.Multivariate logistic analysis was conducted to assess the factors influencing development of a fistula.Receiver operating characteristic(ROC)curves were used to determine the predictive value of serum CRP,PCT,and TBil levels on day 1 postsurgery.RESULTS On day 1 post-surgery,the CRP,PCT,and TBil levels were significantly higher in the pancreatic fistula group than in the non-pancreatic fistula group(P<0.05).A higher fistula grade was associated with higher levels of the indices.Univariate analysis revealed significant differences in the presence of diabetes,hyperlipidemia,pancreatic injury,splenectomy,and the biomarker levels(P<0.05).Logistic multivariate analysis identified diabetes,hyperlipidemia,pancreatic injury,CRP level,and PCT level as independent risk factors.ROC curves yielded predictive values for CRP,PCT,and TBil levels,with the PCT level having the highest area under the curve(AUC)of 0.80[95%confidence interval(CI):0.72-0.90].Combined indicators improved the predictive value,with an AUC of 0.86(95%CI:0.78-0.93).CONCLUSION Elevated CRP,PCT,and TBil levels predict risk of pancreatic fistula post-gastrectomy for gastric cancer.

Petersen's hernia with chylous ascites following laparoscopic total gastrectomy and Roux-en-Y anastomosis:A case report and review of literature

BACKGROUND Petersen’s hernia occurring through the epiploic foramen of the greater omentum,is an uncommon type of internal hernia.When it presents with complications such as chylous ascites,which is the lymphatic fluid accumulation in the abdominal cavity,it is particularly rare.Following laparoscopic total gastrectomy and Roux-en-Y anastomosis,the incidence of this condition is exceedingly low.CASE SUMMARY A 62-year-old male patient developed Petersen’s hernia following laparoscopic total gastrectomy(LTG)for gastric cancer,after Roux-en-Y anastomosis.Intestinal torsion and obstruction were experienced by the patient,along with a small amount of chylous ascites.Imaging studies and clinical assessment confirmed the diagnosis.Emergency surgery was performed promptly for the patient in the operating room.The twisted small intestine was reduced and the defect in Petersen’s space was repaired.The procedure was successful in the correction of the intestinal torsion and approximation of the hernia without the need for bowel resection.The patient’s condition significantly improved following the surgery.The ascites evolved from a milky white appearance to a pale yellow,with a substantial decrease in the triglyceride levels in the ascitic fluid,implying a favorable recovery trajectory.The patient was monitored closely and received appropriate care postoperatively,including nutritional support and fluid management.CONCLUSION This report illustrates the significance of recognizing Petersen’s hernia as a potential complication following gastrectomy for gastric cancer.It highlights the fundamental role of early surgical intervention in the effective management of such complications.The favorable outcome in this patient illustrates that prompt and appropriate surgical management can deter the necessity for more extensive procedures such as bowel resection.

Current status of function-preserving surgery for gastric cancer

Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer(GC)at an early stage.Due to the low incidence of lymph node metastasis and favorable prognosis in early GC,function-preserving surgery which improves postoperative quality of life may be possible.Pylorus-preserving gastrectomy(PPG)is one such function-preserving procedure,which is expected to offer advantages with regards to dumping syndrome,bile reflux gastritis,and the frequency of flatus,although PPG may induce delayed gastric emptying.Proximal gastrectomy(PG)is another functionpreserving procedure,which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach,although the incidence of heartburn or gastric fullness associated with this procedure is high.However,these disadvantages may be overcome by the reconstruction method used.The other important problem after PG is remnant GC,which was reported to occur in approximately 5%of patients.Therefore,the reconstruction technique used with PG should facilitate postoperativeendoscopic examinations for early detection and treatment of remnant gastric carcinoma.Oncologic safety seems to be assured in both procedures,if the preoperative diagnosis is accurate.Patient selection should be carefully considered.Although many retrospective studies have demonstrated the utility of function-preserving surgery,no consensus on whether to adopt functionpreserving surgery as the standard of care has been reached.Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.

Pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy(PPG)has been widely accepted as a function-preserving gastrectomy for middle-third early gastric cancer(EGC)with a distal tumor border at least 4 cm proximal to the pylorus.The procedure essentially preserves the function of the pyloric sphincter,which requires to preserve the upper third of the stomach and a pyloric cuff at least 2.5 cm.The suprapyloric and infrapyloric vessels are usually preserved,as are the hepatic and pyloric branches of the vagus nerve.Compared with distal gastrectomy,PPG has significant advantages in preventing dumping syndrome,body weight loss and bile reflux gastritis.The postoperative complications after PPG have reached an acceptable level.PPG can be considered a safe,effective,and superior choice in EGC,and is expected to be extensively performed in the future.

Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND Laparoscopic radical gastrectomy is widely used,and perioperative complications have become a highly concerned issue.AIM To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery,guide perioperative treatment strategies for gastric cancer patients,and prevent serious complications.METHODS In total,998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model,and 398 patients were included in the validation group.The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected.Three machine learning methods,lasso regression,random forest,and artificial neural networks,were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy,and their prediction efficacy and accuracy were evaluated.RESULTS The constructed complication model,particularly the random forest model,could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy.It exhibited stable performance in external validation and is worthy of further promotion in more centers.CONCLUSION Using the risk factors identified in multicenter datasets,highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established.We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

Clinical significance of preoperative nutritional status in elderly gastric cancer patients undergoing radical gastrectomy:A singlecenter retrospective study

BACKGROUND The population of elderly patients with gastric cancer is increasing,which is a major public health issue in China.Malnutrition is one of the greatest risk factors for adverse clinical outcomes in elderly patients with gastric cancer.AIM To investigate the preoperative nutritional status and its association with delayed discharge of elderly gastric cancer patients following radical gastrectomy.METHODS A total of 783 patients aged 65 years and older harboring gastric adenocarcinoma and following radical gastrectomy were retrospectively analyzed from the prospectively collected database of Zhongshan Hospital of Fudan University between January 2018 and May 2020.RESULTS The overall rate of malnutrition was 31.8%.The incidence of postoperative complications was significantly higher in the malnourished group compared to the well-nourished group(P<0.001).Nutritional characteristics in the malnourished group,including body mass index,prognostic nutritional index(PNI),albumin,prealbumin,and hemoglobin,were all significantly lower than those in the well-nourished group.The percentage of patients who received postoperative total nutrient admixture was lower in the malnourished group compared to the wellnourished group(22.1%vs 33.5%,P=0.001).Age≥70 years(HR=1.216,95%CI:1.048-1.411),PNI<44.5(HR=1.792,95%CI:1.058-3.032),operation time≥160 minutes(HR=1.431,95%CI:1.237-1.656),and postoperative complications grade III or higher(HR=2.191,95%CI:1.604-2.991)were all recognized as independent risk factors associated with delayed discharge.CONCLUSION Malnutrition is relatively common in elderly patients undergoing gastrectomy.Low PNI is an independent risk factor associated with delay discharge.More strategies are needed to improve the clinical outcome of these patients.

Association between operative position and postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy

BACKGROUND Bariatric surgery is one of the most effective ways to treat morbid obesity,and postoperative nausea and vomiting(PONV)is one of the common complications after bariatric surgery.At present,the mechanism of the high incidence of PONV after weight-loss surgery has not been clearly explained,and this study aims to investigate the effect of surgical position on PONV in patients undergoing bariatric surgery.AIM To explore the effect of the operative position during bariatric surgery on PONV.METHODS Data from obese patients,who underwent laparoscopic sleeve gastrectomy(LSG)in the authors’hospital between June 2020 and February 2022 were divided into 2 groups and retrospectively analyzed.Multivariable logistic regression analysis and the t-test were used to study the influence of operative position on PONV.RESULTS There were 15 cases of PONV in the supine split-leg group(incidence rate,50%)and 11 in the supine group(incidence rate,36.7%)(P=0.297).The mean operative duration in the supine split-leg group was 168.23±46.24 minutes and 140.60±32.256 minutes in the supine group(P<0.05).Multivariate analysis revealed that operative position was not an independent risk factor for PONV(odds ratio=1.192,95%confidence interval:0.376-3.778,P=0.766).CONCLUSION Operative position during LSG may affect PONV;however,the difference in the incidence of PONV was not statistically significant.Operative position should be carefully considered for obese patients before surgery.

Comparison efficacy and safety of total laparoscopic gastrectomy and laparoscopically assisted total gastrectomy in treatment of gastric cancer

BACKGROUND The development of laparoscopic technology has provided a new choice for surgery of gastric cancer(GC),but the advantages and disadvantages of laparoscopic total gastrectomy(LTG)and laparoscopic-assisted total gastrectomy(LATG)in treatment effect and safety are still controversial.The purpose of this study is to compare the efficacy and safety of the two methods in the treatment of GC,and to provide a basis for clinical decision-making.AIM To compare the efficacy of totally LTG(TLTG)and LATG in the context of radical gastrectomy for GC.Additionally,we investigated the safety and feasibility of the total laparoscopic esophagojejunostomy technique.METHODS Literature on comparative studies of the above two surgical methods for GC(TLTG group and LATG group)published before September 2022 were searched in the PubMed,Web of Science,Wanfang Database,CNKI,and other Chinese and English databases.In addition,the following search keywords were used:Gastric cancer,total gastrectomy,total laparoscopy,laparoscopy-assisted,esophagojejunal anastomosis,gastric/stomach cancer,total gastrectomy,totally/completely laparoscopic,laparoscopic assisted/laparoscopy assisted/laparoscopically assisted,and esophagojejunostomy/esophagojejunal anastomosis.Review Manager 5.3 software was used for the meta-analysis after two researchers independently screened the literature,extracted the data,and evaluated the risk of bias in the included studies.RESULTS After layer-by-layer screening,258 pieces of literature were recovered,and 11 of those pieces were eventually included.This resulted in a sample size of 2421 instances,with 1115 cases falling into the TLTG group and 1306 cases into the LATG group.Age or sex differences between the two groups were not statistically significant,according to the meta-analysis,however the average body mass index of the TLTG group was considerably higher than that of the LATG group(P=0.01).Compared with those in the LATG group,the incision length in the TLTG group was significantly shorter(P<0.001),the amount of intraoperative blood loss was significantly lower(P=0.003),the number of lymph nodes removed was significantly greater(P=0.04),and the time of first postoperative feeding and postoperative hospitalization were also significantly shorter(P=0.03 and 0.02,respectively).There were no significant differences in tumor size,length of proximal incisal margin,total operation time,anastomotic time,postoperative pain score,postoperative anal exhaust time,postoperative anastomosis-related complications(including anastomotic fistula,anastomotic stenosis,and anastomotic hemorrhage),or overall postoperative complication rate(P>0.05).CONCLUSION TLTG and esophagojejunostomy are safe and feasible.Compared with LATG,TLTG has the advantages of less trauma,less bleeding,easier access to lymph nodes,and faster postoperative recovery,and TLTG is also suitable for obese patients.

Novel subtype of obesity influencing the outcomes of sleeve gastrectomy:Familial aggregation of obesity

BACKGROUND Differences in the preoperative characteristics and weight loss outcomes after sleeve gastrectomy(SG)between patients with familial aggregation of obesity(FAO)and patients with sporadic obesity(SO)have not been elucidated.AIM To explore the impact of SG on weight loss and the alleviation of obesity-related comorbidities in individuals with FAO.METHODS A total of 193 patients with obesity who underwent SG were selected.Patients with FAO/SO were matched 1:1 by propensity score matching and were categorized into 4 groups based on the number of first-degree relatives with obesity(1 SO vs 1FAO,2SO vs 2FAO).The baseline characteristics,weight loss outcomes,prevalence of obesity-related comorbidities and incidence of major surgeryrelated complications were compared between groups.RESULTS We defined FAO as the presence of two or more first-degree relatives with obesity.Patients with FAO did not initially show significant differences in baseline data,short-term postoperative weight loss,or obesity-related comorbidities when compared to patients with SO preoperatively.However,distinctions between the two groups became evident at the two-year mark,with statistically significant differences in both percentage of total weight loss(P=0.006)and percentage of excess weight loss(P<0.001).The FAO group exhibited weaker remission of type 2 diabetes mellitus(T2DM)(P=0.031),hyperlipidemia(P=0.012),and non-alcoholic fatty liver disease(NAFLD)(P=0.003)as well as a lower incidence of acid reflux(P=0.038).CONCLUSION FAO patients is associated with decreased mid-to-long-term weight loss outcomes;the alleviation of T2DM,hyperlipidemia and NAFLD;and decreased incidence of acid reflux postoperatively.

Advances in artificial intelligence for predicting complication risks post-laparoscopic radical gastrectomy for gastric cancer:A significant leap forward

In a recent paper,Hong et al developed an artificial intelligence(AI)-driven predictive scoring system for potential complications following laparoscopic radical gastrectomy for gastric cancer patients.They demonstrated that integrating AI with random forest models significantly improved the preoperative prediction and patient outcome management accuracy.By incorporating data from multiple centers,their model ensures standardization,reliability,and broad applicability,distinguishing it from the prior models.The present study highlights AI's potential in clinical decision support,aiding in the preoperative and postoperative management of gastric cancer patients.Our findings may pave the way for future prospective studies to further enhance AI-supported diagnoses in clinical practice.

Effect of visceral obesity on outcomes of fluorescence-guided lymphadenectomy during laparoscopic gastrectomy for gastric cancer:Post hoc analysis of a randomized phase 3 trial

Objective:To explore the impact of visceral fat area(VFA)on the short-and long-term efficacy of indocyanine green(ICG)-guided D2 lymphadenectomy for gastric cancer(GC).Methods:A post hoc analysis was performed in patients who participated in a phase 3 randomized clinical trial of ICG-guided laparoscopic radical gastrectomy vs.conventional laparoscopic radical gastrectomy from November 2018 to July 2019.The VFA was calculated based on preoperative computed tomography images.Short-term efficacy included the quality of lymph node(LN)dissection and surgical outcomes,while long-term efficacy included overall survival(OS)and recurrence-free survival(RFS).Results:This study included 126 patients each in the ICG(high-VFA,n=43)and non-ICG groups(high-VFA,n=38).Compared with the non-ICG group,the ICG group had significantly more retrieved LNs(low-VFA:50.1 vs.43.9,P=0.001;high-VFA:49.6 vs.37.5,P<0.001)and a significantly lower LN noncompliance rate(low-VFA:32.5%vs.50.0%,P=0.020;high-VFA:32.6%vs.73.7%,P<0.001),regardless of the VFA.The ICG group had a shorter postoperative hospital stay and fewer intra-abdominal infections than the ICG group in the high-VFA patients(P=0.025 and P=0.020,respectively)but not in the low-VFA patients.Regardless of the VFA,the 3-year OS(RFS)was better in the ICG group than in the non-ICG group[low-VFA:83.1%(76.9%)vs.73.9%(67.0%);high-VFA:90.7%(90.7%)vs.73.7%(73.5%);P for interaction=0.474(0.547)].Conclusions:The short-and long-term efficacies of ICG tracing were not influenced by visceral obesity.

Clinical efficacy of modified Kamikawa anastomosis in patients with laparoscopic proximal gastrectomy

BACKGROUND With the increasing incidence of proximal gastric cancer,laparoscopic proximal gastrectomy has been applied.However,reflux esophagitis often occurs after traditional esophagogastric anastomosis.In order to solve this problem,several methods of digestive tract reconstruction have emerged,but the most satisfying method remains to be discussed.Therefore,we modified traditional Kamikawa anastomosis to investigate the appropriate digestive tract reconstruction in laparo-scopic proximal gastrectomy.All the patients were successfully operated on without conversion to laparotomy.The duration of operation and digestive tract reconstruction were 203.500(150-224)min and 87.500(73-111)min,respectively.The intraoperative amount of bleeding was 20.500 mL±0.696 mL.The time of postoperative first flatus,the first postoperative fluid intake,and the postoperative length of stay were 2(1-3)d,4(3-5)d,and 9(8-10)d,respectively.All the patients were followed up for 12-23 months.The body mass index at 6 and 12 months after surgery were 22.577 kg/m2±3.098 kg/m2 and 22.594 kg/m2±3.207 kg/m2,respectively.The nutrition risk screening 2002 score,the patient-generated subjective global assessment score,and the gastroesophageal reflux disease scale score were good at 6 and 12 months after surgery.Reflux esophagitis and anastomotic stenosis were not observed in any of the patients during their 12-month postoperative gastroscopy or upper gastrointestinal tract visits.All the patients exhibited no tumor recurrence or metastasis.CONCLUSION The modified Kamikawa anastomosis is safe and feasible for laparoscopic proximal gastrectomy and has good antireflux effects and nutritional status.

Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy

Objective: This case report aimed to demonstrate a possible neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in association with sleeve gastrectomy plus antrojejunostomy, in order to reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients with previous Sleeve Gastrectomy (SG) who had had weight regain, with or without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique, which may require a revisional procedure. RYGB is an option in such a situation but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient would be of great value for the patients. Methods: We describe herein two cases of SG revision for weight regain and GERD, with a follow-up of one year. Gastroesophageal reflux disease was evaluated by validated questionnaire, upper endoscopy, seriography, high resolution manometry (HRM) and impedance pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve Gastrectomy with antrojejunal anastomosis was done in both cases, after informed consents. The Latarjet nerves were transected in one case, due to a bleeding in the left gastric vessels and a truncal vagotomy was required in the other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both cases, during seriography and endoscopy, kept until the one-year follow-up. There was unidirectional contrast flow to the gastrointestinal anastomosis, filling the jejunal limb, in radiologic contrast study. No contrast passed through the pylorus. Nonetheless, the duodenum was kept endoscopically accessible. In the one-year evaluation, weight loss was adequate and GERD resolution was obtained in both cases, confirmed by endoscopic and functional esophageal assessment, together with symptoms questionnaire. Conclusion: The association of Latarjet nerves sectioning or truncal vagotomy with re-sleeve gastrectomy plus gastrointestinal anastomosis (antrojejunal), in a revision for a failed sleeve, can represent a technical approach, to reproduce RYGB results, without exclusions and with duodenum endoscopic accessibility maintenance. It maybe could be applied for primary surgeries. Additional studies are necessary to confirm this hypothesis.

How to identify early complications in patients undergoing distal gastrectomy?

In this editorial we comment on the article by Zhang et al published in a recent issue of the World Journal of Gastrointestinal Surgery.Gastrectomy with appropriate lymph node dissection is still standard curative treatment in locally advanced gastric cancer.Several studies point out that gastric cancer surgery is a complex procedure that leads to a high risk of morbidity and mortality.Many factors can contribute to the onset of complications with consequent effects on prognosis and increased mortality.The complications can be divided in complications related to anastomosis,to motility and to surgical site infection.The study presented by Zhang B et al represent an interesting analysis on the possibility to prevent postoperative morbidity.The study was performed on 131 patients with distal gastric cancer who underwent gastrectomy with D2 lymph node dissection.Of these patients,16%developed early postoperative complications.The univariate analysis showed that prealbumin level,hypertension,diabetes,history of abdominal surgery,R0 resection,and blood transfusion were factors influencing early postoperative complications after distal gastrectomy.Moreover,the inclusion of the above significant variables in the logistic regression analysis revealed that hypertension,diabetes,a history of abdominal surgery,and blood transfusion were independent predictors of postoperative complications.In conclusion,preoperative and intraoperative factors can be used to establish an early postoperative nomogram model.The results of the study presented by Zhang et al suggest that the prediction model can be used to guide the detection of postoperative complications and has clinical reference value.

Modified hepatic left lateral lobe inversion in laparoscopic proximal gastrectomy: An analysis of 13 cases

BACKGROUND In laparoscopic proximal gastrectomy(LPG),the prolapse of the hepatic left lateral lobe near the lesser curvature and esophageal hiatus can obstruct the field of vision and operation.Therefore,it is necessary to retract or obstruct the hepatic left lateral lobe to ensure a clear field of vision.AIM To investigate the safety and clinical efficacy of the modified hepatic left lateral lobe inversion technique for LPG.METHODS A retrospective analysis was conducted on the clinical data of 13 consecutive patients with early-stage upper gastric adenocarcinoma or adenocarcinoma of the esophagogastric junction treated with LPG from January to December 2023 at the Department of Gastrointestinal Surgery,Second Affiliated Hospital of Fujian Medical University.The modified hepatic left lateral lobe inversion technique was used to expose the surgical field in all patients,and short-term outcomes were observed.RESULTS In all 13 patients,the modified hepatic left lateral lobe inversion technique was successful during surgery without the need for re-retraction or alteration of the liver traction method.There were no instances of esophageal hiatus occlusion,eliminating the need for forceps to assist in exposure.There was no occurrence of intraoperative hepatic hemorrhage,hepatic vein injury,or hepatic congestion.No postoperative digestive complications of Clavien-Dindo grade≥II occurred wi-thin 30 days after surgery,except for a single case of pulmonary infection.Some patients experienced increases in alanine aminotransferase and aspartate aminotransferase levels on the first day after surgery,which significantly decreased by the third day and returned to normal by the seventh day after surgery.CONCLUSION The modified hepatic left lateral lobe inversion technique has demonstrated satisfactory results,offering ad-vantages in terms of facilitating surgical procedures,reducing surgical trauma,and protecting the liver.