The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis.

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Case report: A rare case of sintilimab-induced gastric stenosis and literature review.

Sintilimab is a fully human IgG4 monoclonal antibody against programmed death-1 (PD-1) used to treat classical Hodgkin's lymphoma and various solid tumors. With increasing use of sintilimab, some rare adverse reactions have been reported. Here, we report a case of a 50-year-old woman with squamous non-small cell lung cancer (NSCLC) (metastasis to pericardium and pleura) who received two cycles of 200 mg sintilimab immunotherapy combined with albumin-bound paclitaxel and carboplatin chemotherapy and one cycle of sintilimab monotherapy. She was diagnosed with Sjogren's syndrome (with symptoms of fever, dry mouth, dysphagia, and eating difficulty) after three cycles' treatment and received standard steroidal therapy. Prior to admission, the patient experienced severe stomach discomfort with vomiting and was hospitalized. Upper gastrointestinal iodine angiography showed significant gastric stenosis as well as lower esophageal stenosis. Subsequent ultrafine gastroscopy revealed ulceration at the stenotic site and an absence of normal peristalsis of the gastric wall. Pathological examination of the lesions showed reactive changes, including ulceration, fibrosis, and inflammatory cell infiltration. After multidisciplinary consultation, it was considered that the patient's gastric stenosis with inflammatory fibrosis changes was due to a sintilimab-induced immune hyperinflammatory reaction. The patient had been treated with standard steroidal therapy since suffering from Sjogren's syndrome, but the gastric stenotic changes were not relieved. The patient then received regular bouginage of esophago-cardiac stenosis under gastroscopy to physically reexpand the fibrous hyperplasia and stenotic site, enabling normal eating function. To our knowledge, this is the first case of gastric stenosis in a patient with squamous NSCLC after using sintilimab and may help clinicians better understand potential immune-related adverse events due to sintilimab and improve assessment and management.

The utility of intraoperative endoscopy to assist novice surgeons in the detection of gastric stenosis during laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Gastric stenosis and leaks are 2 major complications associated with LSG and revision surgery might be needed. Herein, we report our experience of intraoperative endoscopy (IOE) to evaluate stenosis and leaks during LSG. METHODS: LSG was performed by three surgeons. Patients who underwent LSG and IOE between January 2016 and March 2020 were enrolled and assigned to two groups: group 1 (1st-30th LSG case for each surgeon) and group 2 (> 30th LSG for each surgeon). Patients' anthropometric and biochemical data pre- and post-LSG, as well as IOE findings and follow-up esophagogastroduodenoscopy records were reviewed. RESULTS: In total, 352 patients were enrolled including 90 patients in group 1 and 262 patients in group 2. Three out of 352 patients (0.9%) were found to have stenosis by IOE, which was related to tightly gastropexy stitch or reinforcement stitch, all of which were in group 1. Stenosis was resolved after removal of the stitch during LSG. The incidence of gastric stenosis detected by IOE was 3.3% (3/90) and 0% (0/262) in group 1 and group 2, respectively (P = 0.003). No leakage was found in this study and no patient developed clinical or endoscopic stenosis after LSG. CONCLUSIONS: The existing evidence showed that IOE can help detect gastric stenosis during LSG, especially for novice surgeons, and the stenosis could be resolved during operation.

A caustic ingestion consequence mistaken for gastric cancer: A case report.

INTRODUCTION: This report is a case of a suicide attempt by bleach ingestion. mistaken for gastric cancer after oral contrast studies and esophagogastroduodenoscopy. We report this case to encourage physicians to take this etiology into consideration as part of differential diagnosis especially in front of a secretive patient. PRESENTATION OF CASE: We report a case of a 38-year-old lady admitted for an acute onset of symptoms leading to a diagnosis of antral stenosis. Further workup which included endoscopic and surgical biopsies failed to reveal an underlying malignancy. After 24 days of inconclusive inpatient investigations, and due to failure of conservative treatment, distal gastrectomy was performed. Final pathology also revealed an absence of any signs of malignancy, and reported only inflammatory changes. One month after discharge, the patient confessed that she had attempted suicide by ingestion of corrosive agents before the symptoms started and wanted to keep the incident as a secret. DISCUSSION: Gastric stenosis is seldom encountered in adult patients, however, it can occasionally result secondary to gastric ulcer disease, malignancies, foreign body ingestion, certain drugs or chemicals, or after endoscopic or surgical interventions. These etiologies do not usually cause acute gastric obstruction, and usually follow a more indolent course. Identification of an underlying etiology is mandatory to determine the proper medical or surgical treatment to relieve the obstructive symptoms. CONCLUSION: We report this bizarre case to encourage physicians to keep this etiology in mind in otherwise unexplained gastric stenosis.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management.

BACKGROUND: Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG. METHODS: This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment. RESULTS: Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients. CONCLUSION: PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.

[Staged endoscopic balloon dilatation for cicatricial pyloric stenosis in children]. / Opyt poétapnoi éndoskopicheskoi ballonnoi dilatatsii pri rubtsovykh stenozakh privratnika u detei.

Secondary pyloric stenosis quickly leads to homeostatic and nutritional disorders that determines the importance of early diagnosis and surgical treatment. In two clinical cases, we have shown that staged endoscopic balloon dilatation of the pylorus is devoid of the most of the known problems and shortcomings of conventional surgery and makes it possible to restore effectively gastrointestinal passage and to improve child's quality of life. This procedure has a high diagnostic and curative value and is followed by positive dynamics of condition of the child with pyloric stenosis.

Gastric Per-Oral Endoscopic Myotomy (G-POEM) for the Treatment of Gastric Stenosis Post-Laparoscopic Sleeve Gastrectomy (LSG).

Laparoscopic sleeve gastrectomy (LSG) has become the most common form of bariatric surgery performed worldwide. However, it is associated with potentially debilitating adverse events such as post-operative stenosis. Finding effective and minimally invasive treatments for such complications is of paramount importance. Gastric per-oral endoscopic myotomy (G-POEM) is a novel procedure developed over the past decade to treat conditions that delay gastric emptying. We present a case demonstrating the use of G-POEM in the successful endoscopic management of post-LSG gastric stenosis.

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure.

Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

An Algorithmic Approach to the Management of Gastric Stenosis Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG. METHODS: Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB). RESULTS: Total of 17 patients underwent a median of 2 (range 1-4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score ± SD, was in the following items: nausea (3 ± 1.9, P < 0.001), heartburn during day (2.8 ± 1.5, P = 0.003), heartburn on lying down (3.4 ± 1.4, P < 0.001), reflux during day (2.8 ± 1.9, P < 0.001), and reflux on lying down (3.0 ± 1.9, P < 0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB. CONCLUSIONS: Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB.

Gastropancreatic ligament: Description, incidence, and involvement during laparoscopic sleeve gastrectomy.

During laparoscopic sleeve gastrectomy (LSG), adhesions between the stomach and the pancreas are sometimes found, forming a "gastropancreatic ligament" (GPL). However, the GPL has only been described once in the literature, in 1985. The objective of this study was to determine the incidence of the GPL during LSG, describe this structure and assess its effect on the surgical technique. All patients undergoing primary LSG in our institution (n = 240) and patients referred for gastric fistula (GF) after primary LSG (n = 18) between January 2015 and December 2015 were included. The primary endpoint was the incidence of a GPL during primary LSG. The secondary endpoints were the postoperative complication rate, the postoperative GF rate, and the presence of this ligament during reoperation for GF. Among the 240 patients, a GPL was visible in 49 cases (20.4%) and was described as thin in 34 of these (69.4%). Twelve postoperative complications (5%) were observed, including seven major (2.9%). The GF rate was 2% (n = 5), not requiring reoperation. The gastric stenosis rate was 0.4% (n = 1). The GPL had been previously sectioned in one of the five patients (20%) with postoperative GF. During the study period, 18 patients were referred for GF and 14 were reoperated. A non-sectioned GPL, not described in the operating report, was observed in four patients (28.5%). A GPL was identified in 20.4% of cases. Identification of a GPL could be important in the context of LSG, as section of the ligament allows tension-free stapling to be performed and can therefore possibly reduce the risk of postoperative complications, particularly GF. Clin. Anat. 30:336-341, 2017. © 2017 Wiley Periodicals, Inc.

Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is accepted as a stand-alone bariatric procedure. A specific and potentially severe complication of LSG is gastric stenosis (GS). OBJECTIVE: Reviewing the treatment and prevention of GS after LSG. SETTING: University hospital, Taiwan. MATERIALS AND METHODS: A retrospective analysis was conducted involving all of the LSG cases (n = 927) at our institution between February 2007 and December 2015. RESULTS: Eight patients (0.8%) with GS were identified in our unit and 1 patient was transferred from another institution with symptomatic GS. The median intervals from initial LSG to the presence of symptoms, endoscopic dilation, and surgical revision were 14±30 days (range, 7-103 days), 21±35.6 days (range, 9-110 days), and 36±473.9 days (range, 11-1185 days), respectively. The majority of stenoses were located at the incisura angularis (8/9 [88.9%]). Among the 9 patients, only 1 responded satisfactorily to repetitive endoscopic dilation and the remaining 8 patients required revisional laparoscopic surgery, including conversion to Roux-en-Y gastric bypass (n = 6), stricturoplasty (n = 1), and Roux-en-Y gastric bypass after failed seromyotomy (n = 1). No patients experienced recurrent symptoms of GS after revisional surgery. In September 2013, we modified our surgical techniques for the subsequent 489 patients and GS did not occur after the change in surgical procedures. CONCLUSION: A combined treatment modality, endoscopic intervention with and without surgical revision is essential for managing GSs. Based on our own experience, we emphasize the clinical significance of surgical standardization to prevent the occurrence of GS.

Risk factors and management for gastric stenosis after endoscopic submucosal dissection for gastric epithelial neoplasm.

BACKGROUND: Only a few studies have reported treatment options for stenosis after endoscopic submucosal dissection (ESD) for gastric neoplasms. This study aimed to identify the risk factors for and evaluate the management of stenosis after ESD for gastric epithelial neoplasms in the cardia and antrum. METHODS: We retrospectively reviewed 1218 patients (1447 gastric epithelial neoplasms) who underwent ESD at Tonan Hospital from June 2004 to November 2015. Post-ESD stenosis was defined when a standard endoscope could not be passed through the site. RESULTS: Post-ESD stenosis occurred in 10 (21.3%) of the 47 cardia cases and 14 (3.2%) of the 432 antrum cases. A wide resection of more than three fourths of the circumferential extent was the sole significant risk factor related to post-ESD stenosis in both cardia and antrum. Prophylactic endoscopic balloon dilation (EBD) was performed in 3 of 10 patients with cardiac stenosis and 4 of 14 with antral stenosis. Post-EBD bleeding occurred in one cardia (10%) and one antrum (7.1%) case each and was endoscopically treated. Perforation during EBD occurred in two (14.3%) antrum cases, both of which required emergency open surgery. All complications were observed in patients with conventional EBD, and no complications were associated with prophylactic EBD. CONCLUSIONS: A wide resection of more than three fourths of the circumferential extent was the significant risk factor for post-ESD stenosis in both cardia and antrum, and prophylactic EBD could be a promising procedure for the management of post-ESD stenosis.

Endoscopic management of unresectable malignant gastroduodenal obstruction with a nitinol uncovered metal stent: A prospective Japanese multicenter study.

AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction. METHODS: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, self-expandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline. RESULTS: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients (10.3%) in the form of mild pneumonitis. No other morbidities or mortalities were observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients (7.7%) on account of tumor growth. CONCLUSION: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients' quality of life.

[Ingestion of caustic substances in children: 3 years of experience]. / Ingesta de cáusticos en niños, experiencia de 3 años.

INTRODUCTION: There is no clear consensus on the management of accidental ingestion of caustic substances in paediatrics. The aim of this study was to determine the profile of the paediatric population treated due to caustic ingestion in a Healthcare Centre. PATIENTS AND METHOD: A descriptive study was conducted on patients treated for the ingestion of caustic substances in our hospital during the period 2008-2011. RESULTS: A total of 12 patients were treated, with a mean age of 3.8 years (1-13 years), with the majority males (58.8%). An alkaline product was ingested by 58.3%, and an acid by 41.6%. The majority (58.3%) did not refer to symptoms and the remainder referred to vomiting (33.3%), odynophagia (16.6%), haematemesis (8.3%), hyper-salivation (8.3%) and shortness of breath (8.3%). Oral cavity lesions were observed in 75% of cases. All, except one, were accidental. An endoscopy was performed on all of them (100%) between 12 and 24hours post-ingestion, with pathological findings in 41.6%. In the group that ingested an alkali, 2 (16.6%) patients had lesions, one a grade 2B and one a grade 3 oesophagitis. In the acid ingestion group, 4 (33.3%) patients had lesions; one grade 1-2A oesophagitis, two acute non-erosive gastritis, and one acute haemorrhagic gastritis. A follow-up endoscopy was performed depending on the previous endoscopic findings. Only two patients presented with complications. CONCLUSIONS: Emphasis is placed on the endoscopic evaluation in the first 24hours of deliberate asymptomatic ingestions, as well as a strict follow-up in those that ingested acids, due to delayed associated lesions.

Ingesta de cáusticos en niños, experiencia de 3 años / Ingestion of caustic substances in children: 3 years of experience

Introdución: La ingesta accidental de cáusticos en pediatría no dispone de un consenso claro de actuación. El objetivo de este estudio fue caracterizar la población pediátrica atendida por ingesta de cáusticos en un centro asistencial. Pacientes y método: Estudio descriptivo de los pacientes atendidos en nuestro hospital por la ingesta de cáusticos durante el período 2008-2011. Resultados: Se atendieron 12 pacientes, edad media de 3,8 años (1-13 años). Predominio de varones (58,8%). Un 58,3% ingirió producto alcalino y un 41,6% ácido. El 58,3% no refería sintomatología, el resto refirió vómitos (33,3%), odinofagia (16,6%), hematemesis (8,3%), sialorrea (8,3%) y dificultad respiratoria (8,3%). El 75% presentaron lesiones en la cavidad oral. Todos, salvo un caso, fueron accidentales. Se realizó endoscopia al 100% entre las 12 y 24 h postingesta con hallazgos patológicos en un 41,6%. En el grupo ingesta de álcalis 2 pacientes presentaron lesiones (16,6%): una esofagitis grado 2B y una grado 3. En el grupo ingesta de ácidos 4 pacientes (33,3%) presentaron lesiones: una esofagitis aguda grado 1-2A, 2 gastritis agudas no erosivas y una gastritis aguda hemorrágica. Se realizó endoscopia de control según los hallazgos endoscópicos previos. Solo 2 presentaron complicaciones posteriores. Conclusiones: Destacamos la valoración endoscópica en las primeras 24 h en todas las ingestas sintomáticas y deliberadas, así como la reevaluación estrecha en las ingestas ácidas, por asociar lesiones diferidas.

Introduction: There is no clear consensus on the management of accidental ingestion of caustic substances in paediatrics. The aim of this study was to determine the profile of the paediatric population treated due to caustic ingestion in a Healthcare Centre. Patients and method: A descriptive study was conducted on patients treated for the ingestion of caustic substances in our hospital during the period 2008-2011. Results: A total of 12 patients were treated, with a mean age of 3.8 years (1-13 years), with the majority males (58.8%). An alkaline product was ingested by 58.3%, and an acid by 41.6%. The majority (58.3%) did not refer to symptoms and the remainder referred to vomiting (33.3%), odynophagia (16.6%), haematemesis (8.3%), hyper-salivation (8.3%) and shortness of breath (8.3%). Oral cavity lesions were observed in 75% of cases. All, except one, were accidental. An endoscopy was performed on all of them (100%) between 12 and 24 hours post-ingestion, with pathological findings in 41.6%. In the group that ingested an alkali, 2 (16.6%) patients had lesions, one a grade 2B and one a grade 3 oesophagitis. In the acid ingestion group, 4 (33.3%) patients had lesions; one grade 1-2A oesophagitis, two acute non-erosive gastritis, and one acute haemorrhagic gastritis. A follow-up endoscopy was performed depending on the previous endoscopic findings. Only two patients presented with complications. Conclusions: Emphasis is placed on the endoscopic evaluation in the first 24 hours of deliberate asymptomatic ingestions, as well as a strict follow-up in those that ingested acids, due to delayed associated lesions.

Adverse events associated with endoscopic dilation for gastric stenosis after endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Gastric stenosis is a major problem after endoscopic submucosal dissection (ESD) for large early gastric cancer, but little is known about the incidence of adverse events associated with endoscopic dilation (ED) for stenosis caused by gastric ESD. The aims of this study were to determine the incidence and risk of bleeding and perforation associated with ED for gastric stenosis after ESD. METHODS: This was a single-center, retrospective cohort study conducted at a specialized center for treating cancer. A total of 342 procedures of wire-guided balloon ED were performed for stenosis after gastric ESD in 64 patients. The incidence of adverse events and related clinical characteristics was analyzed. RESULTS: The incidence of bleeding was 3.1% (2/64) per patient and 0.6% (2/342) per procedure. One bleeding case with incomplete cessation of antithrombotics before ED required blood transfusion. The incidence of perforation was 7.8% (5/64) per patient and 1.5% (5/342) per procedure. All perforations occurred in the lower part of the stomach. Two of the five perforation cases were inappropriate for nonoperative therapy, and thus, emergency surgery was performed. Among the other three perforation cases, one case required surgery for refractory stenosis and ED was continued in one case after nonoperative therapy. CONCLUSIONS: The incidence of bleeding caused by ED for gastric stenosis after ESD was small. Although not significant, ED in the lower stomach presents a substantial risk of perforation.

Evaluation of salvage surgery for type 4 gastric cancer.

Patients with type 4 gastric cancer and peritoneal metastasis respond better to chemotherapy than surgery. In particular, patients without gastric stenosis who can consume a meal usually experience better quality of life (QOL). However, some patients with unsuccessful chemotherapy are unable to consume a meal because of gastric stenosis and obstruction. These patients ultimately require salvage surgery to enable them to consume food normally. We evaluated the outcomes of salvage total gastrectomy after chemotherapy in four patients with gastric stenosis. We determined clinical outcomes of four patients who underwent total gastrectomy as salvage surgery. Outcomes were time from chemotherapy to death and QOL, which was assessed using the Support Team Assessment Schedule-Japanese version (STAS-J). Three of the patients received combination chemotherapy [tegafur, gimestat and otastat potassium (TS-1); cisplatin]. Two of these patients underwent salvage chemotherapy after 12 and 4 mo of chemotherapy. Following surgery, they could consume food adequately and their STAS-J scores improved, so their treatments were continued. The third patient underwent salvage surgery after 7 mo of chemotherapy. This patient was unable to consume food adequately after surgery and developed surgical complications. His clinical outcomes at 3 mo were very poor. The fourth patient received combination chemotherapy (TS-1 and irinotecan hydrochloride) for 6 mo and then underwent received salvage surgery. After surgery, he could consume food adequately and his STAS-J score improved, so his treatment was continued. After the surgery, he enjoyed his life for 16 mo. Of four patients who received salvage total gastrectomy after unsuccessful chemotherapy, the QOL improved in three patients, but not in the other patient. Salvage surgery improves QOL in most patients, but some patients develop surgical complications that prevent improvements in QOL. If salvage surgery is indicated, the surgeon and/or oncologist must provide the patient with a clear explanation of the purpose of surgery, as well as the possible risks and benefits to allow the patient to reach an informed decision on whether to consent to the procedure.