Characteristics of Metachronous Remnant Gastric Cancer After Proximal Gastrectomy: A Retrospective Analysis.

PURPOSE: Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability. MATERIALS AND METHODS: We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum. RESULTS: Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudo-fornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010). CONCLUSIONS: Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

[Double-tract reconstruction after gastrectomy for gastric cancer in patients with concomitant cardiovascular diseases]. / Rekonstruktsiya double-tract posle gastrektomii po povodu raka zheludka u patsientov s konkuriruyushchimi serdechno-sosudistymi zabolevaniyami.

OBJECTIVE: To demonstrate the capabilities and advantages of double-tract reconstruction after gastrectomy for gastric cancer and simultaneous approach in surgical treatment of patients with cardiovascular diseases and gastric cancer. MATERIAL AND METHODS: We present two cases of double-tract reconstruction after gastrectomy and the gastric stump extirpation as a part of simultaneous surgical approach to patients with gastric cancer and cardiovascular diseases. A 62-year-old patient underwent simultaneous gastrectomy with double-tract reconstruction (for the first time In Russia) and aortofemoral replacement. A 61-year-old patient underwent simultaneous coronary artery bypass surgery, gastric stump extirpation with esophagogastrostomy and double-tract reconstruction. RESULTS: In 1 case, postoperative period was complicated by subcompensated stenosis of the right ureter due to hematoma near the right common iliac artery. This event required endoscopic stenting of the right ureter with positive effect. Both patients were discharged in 16 and 23 days after surgery. CONCLUSION: This method may be alternative to modern reconstructions. Currently, digestive tract reconstruction after gastrectomy is still important and requires further study. Simultaneous procedures in patients with cancer and cardiovascular disease became more widespread. To objectify our statements, further research is needed.

Remnant Gastrectomy and Gastric Bypass: A Systematic Review of Indications and Outcomes of Resectional Gastric Bypass.

BACKGROUND: In this systematic review, we aim to evaluate the reasons and outcomes behind remnant gastrectomy with or after gastric bypass procedures. RESULTS: A total of 66 studies examining 1918 patients were included in this study with 70% of female predominance. Twenty studies reported RGB on 1751 patients and 46 studies reported remnant gastrectomy after gastric bypass in 167 patients. The most common etiology of RGB was related to the in situ remnant stomach neoplasia in 10 studies on 981 patients; mostly for preventive intentions in high prevalence areas. Remnant gastrectomy after gastric bypass was performed to treat a complication such as GGF, retrograde bile reflux gastritis, cancer mostly adenocarcinoma. Studies revealed that RGB has similar weight loss in comparison to standard Roux-en-Y gastric bypass.

Identification of prognostic signatures in remnant gastric cancer through an interpretable risk model based on machine learning: a multicenter cohort study.

OBJECTIVE: The purpose of this study was to develop an individual survival prediction model based on multiple machine learning (ML) algorithms to predict survival probability for remnant gastric cancer (RGC). METHODS: Clinicopathologic data of 286 patients with RGC undergoing operation (radical resection and palliative resection) from a multi-institution database were enrolled and analyzed retrospectively. These individuals were split into training (80%) and test cohort (20%) by using random allocation. Nine commonly used ML methods were employed to construct survival prediction models. Algorithm performance was estimated by analyzing accuracy, precision, recall, F1-score, area under the receiver operating characteristic curve (AUC), confusion matrices, five-fold cross-validation, decision curve analysis (DCA), and calibration curve. The best model was selected through appropriate verification and validation and was suitably explained by the SHapley Additive exPlanations (SHAP) approach. RESULTS: Compared with the traditional methods, the RGC survival prediction models employing ML exhibited good performance. Except for the decision tree model, all other models performed well, with a mean ROC AUC above 0.7. The DCA findings suggest that the developed models have the potential to enhance clinical decision-making processes, thereby improving patient outcomes. The calibration curve reveals that all models except the decision tree model displayed commendable predictive performance. Through CatBoost-based modeling and SHAP analysis, the five-year survival probability is significantly influenced by several factors: the lymph node ratio (LNR), T stage, tumor size, resection margins, perineural invasion, and distant metastasis. CONCLUSIONS: This study established predictive models for survival probability at five years in RGC patients based on ML algorithms which showed high accuracy and applicative value.

The safety, feasibility, and oncological outcomes of laparoscopic completion total gastrectomy for remnant gastric cancer: a prospective study with 3-year follow-up (FUGES-004 study).

BACKGROUND: The efficacy of laparoscopic completion total gastrectomy (LCTG) for remnant gastric cancer (RGC) remains controversial. METHODS: The primary outcome was postoperative morbidity within 30 days after surgery. Secondary outcomes included 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence. Inverse probability treatment weighted (IPTW) was used to balance the baseline between LCTG and OCTG. RESULTS: Final analysis included 46 patients with RGC who underwent LCTG at the FJMUUH between June 2016 and June 2020. The historical control group comprised of 160 patients who underwent open completion total gastrectomy (OCTG) in the six tertiary teaching hospitals from CRGC-01 study. After IPTW, no significant difference was observed between the LCTG and OCTG groups in terms of incidence (LCTG vs. OCTG: 28.0 vs. 35.0%, P =0.379) or severity of complications within 30 days after surgery. Compared with OCTG, LCTG resulted in better short-term outcomes and faster postoperative recovery. However, the textbook outcome rate was comparable between the two groups (45.9 vs. 32.8%, P =0.107). Additionally, the 3-year DFS and 3-year OS of LCTG were comparable to those of OCTG (DFS: log-rank P =0.173; OS: log-rank P =0.319). No significant differences in recurrence type, mean recurrence time, or 3-year cumulative hazard of recurrence were observed between the two groups (all P >0.05). Subgroup analyses and concurrent comparisons demonstrated similar trends. CONCLUSIONS: This prospective study suggested that LCTG was noninferior to OCTG in both short-term and long-term outcomes. In experienced centers, LCTG may be considered as a viable treatment option for RGC.

Safe and Accurate Laparoscopic Total Gastrectomy for Remnant Gastric Cancer With Severe Adhesions Using Indocyanine Green Fluorescence Imaging: Guidance in Detection of the Accurate Dissection Layer to Avoid Organ Injury.

Laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) requires advanced techniques due to severe postoperative adhesions and anatomic changes. We performed LTG in 2 patients with RGC using intraoperative indocyanine green (ICG) fluorescence imaging. Both cases previously underwent distal gastrectomy with Billroth-I reconstruction for gastric cancer and were subsequently diagnosed with early-stage gastric cancer of the remnant stomach. Indocyanine green (2.5 mg/body) was administered intravenously during surgery. The liver and common bile duct were clearly visualized during surgery using near-infrared fluorescence laparoscopy, and the adhesions between the hepatobiliary organs and remnant stomach were safely dissected. Laparoscopic total gastrectomy was successfully performed without complications, and the postoperative course was uneventful in both cases. Intraoperative real-time ICG fluorescence imaging allows clear visualization of the liver and common bile duct and can be useful in LTG for RGC with severe adhesions.

Efficacy of transcatheter arterial embolization in treating nonvariceal gastric remnant bleeding: a retrospective 5-year study.

BACKGROUND: Gastric remnant bleeding is a special case of upper gastrointestinal bleeding with certain specific disease characteristics, and some matters of transcatheter arterial embolization (TAE) for hemostasis need attention. In this study, we aimed to explore the clinical use of TAE in patients with nonvariceal gastric remnant bleeding and identify the factors influencing the clinical efficacy of these interventions. METHODS: Data were retrospectively analyzed from 42 patients for whom angiography and embolization were performed but could not be treated endoscopically or had failed endoscopic management in our department between January 2018 and January 2023 due to nonvariceal gastric remnant bleeding. We investigated the relationship between the incidence of re-bleeding and the following variables: sex, age, pre-embolization gastroscopy/contrast-enhanced computer tomography, embolization method, aortography performance, use of endoscopic titanium clips, and the presence of collateral gastric-supplying arteries. RESULTS: Forty-two patients underwent 47 interventional embolizations. Of these, 16 were positive for angiographic findings, and 26 were negative. Based on arteriography results, different embolic agents were selected, and the technical success rate was 100%. The incidence of postoperative re-bleeding was 19.1% (9/47), and the overall clinical success rate was 81.0% (34/42). Logistic regression analysis of the relationship between the incidence of early re-bleeding following embolization and the proportion of collateral gastric supply arteries revealed an odds ratio of 10.000 (p = 0.014). CONCLUSIONS: Utilizing TAE for nonvariceal gastric remnant bleeding is safe and effective. The omission of collateral gastric-supplying arteries can lead to early re-bleeding following an intervention.

Incidence and risk of remnant gastric cancer after gastrectomy for gastric cancer: a population-based study from the SEER database.

BACKGROUND: Gastric cancer (GC) constitutes a major global health problem, of which remnant gastric cancer (RGC) occurs less frequently. The rate of RGCs after gastrectomy for GC is increasing recently due to improved survival and screening, however, their incidence and risk have not been reported in the U.S. POPULATION: The objective of this study was to evaluate the incidence and elevated risk of RGC after GC gastrectomy in this population, and to identify the risk factors. METHODS: Patients underwent gastrectomy for first primary GC in 2000-2015 and those who developed RGC were identified from Surveillance, Epidemiology and End Results (SEER) database. Fine-Gray regression was used to estimate the cumulative incidence and to identify risk factors. Standardized incidence ratios (SIRs) were calculated by Poisson regression to compare the risk with the general population. RESULTS: Among 21,566 patients included in the cohort, 227 developed RGC. The 20-year cumulative incidence of RGC was 1.88%. Multivariate analysis revealed that older age, invasion depth, male sex, marital status, and lower income are independent risk factors for RGC development. SIR was 7.70 overall and > 4.5 in each stratum. CONCLUSIONS: Cumulative incidence and risk for RGCs increased continuously in patients underwent GC gastrectomy. Close and lifelong endoscopy surveillance should be recommended for patients who received GC gastrectomy, especially those with high-risk factors.

[Comparison of quality-of-life after proximal gastrectomy with double tract reconstruction versus gastric tube reconstruction in patients with proximal gastric cancer].

Objective: To compare the surgical safety and postoperative quality of life between proximal gastrectomy with double tract reconstruction (PG-DT) and proximal gastrectomy with gastric tube reconstruction (PG-GT) for proximal gastric cancer. Methods: This was a retrospective cohort study of clinical and follow-up data of 99 patients with proximal gastric cancer who had undergone double tract or gastric tube surgery in Nanjing Drum Tower Hospital from January 2016 to September 2021. We allocated them to two groups according to surgical procedure, namely a double tract group (PG-DT, 50 patients) and gastric tube group (PG-GT, 49 patients). Proximal gastrectomy with double tract reconstruction entails constructing a Roux-en-Y esophagojejunostomy after severing the proximal stomach, and then constructing a side-to-side anastomosis between the residual stomach and the jejunum to establish an anti-reflux barrier and thus minimize postoperative gastroesophageal reflux. Proximal gastrectomy with gastric tube reconstruction entails severing the proximal gastric stomach, constructing a tubular shaped gastric remnant, and then using a linear stapler to directly anastomose the posterior wall of the esophagus to the anterior wall of the resultant gastric tube. The primary end point was the quality of life of the two groups 1 year postoperatively (post-gastrectomy syndrome assessment scale: the higher the scores for change in body mass, food intake per meal, meal quality subscale, total physical health measurement, and total mental health measurement, the better the quality-of-life, and the higher the scores for other indicators, the worse the quality-of-life). The secondary end points were intraoperative and postoperative status, changes in nutritional status 1, 3, 6, and 12 months postoperatively, and long-term postoperative complications (gastroesophageal reflux, anastomotic stenosis, intestinal obstruction, and gastric emptying disorder 1 year postoperatively). Results: In the PG-DT group, there were 35 (70%) men and 15 (30%) women, 33 (66.0%) patients were aged <65 years, and 37 (74.0%) of them had a body mass index of 18-25 kg/m2; whereas in the PG-GT group, there were 41 (83.7%) men and eight (16.3%) women, 21 (42.9%) patients aged <65 years, and 34 (69.4%) patients with a body mass index of 18-25 kg/m2. There were no significant differences in baseline data between the two groups except for age (P=0.021). There were no significant differences in intraoperative blood loss, number of lymph node dissected, length of hospital stay, and incidence of perioperative complications between the two groups (all P>0.05). Compared with the PG-GT group, the incidence and severity of postoperative reflux esophagitis were significantly lower in the PG-DT group (4.0% [2/50] vs. 26.5% [13/49], χ2=13.507, P=0.009). The incidences of postoperative anastomotic stenosis, intestinal obstruction, and gastric retention did not differ significantly between the two groups (all P>0.05). Patients in the PG-DT group had better quality-of-life scores for esophageal reflux (2.8 [2.3,4.0] vs. 4.8 [3.8,5.0], Z=3.489, P<0.001), eating discomfort (2.7 [1.7,3.0] vs. 3.3 [2.7,4.0 ], Z=3.393, P=0.001), and total symptoms (2.3 [1.7,2.7] vs. 2.5 [2.2,2.9], Z=2.243, P=0.025) than those in the gastric tube group; The scores for postoperative symptoms (2.0 [1.0,3.0] vs. 2.0 [2.0, 3.0], Z=2.127, P=0.033), meals consumed (2.0 [1.0, 2.0] vs. 2.0 [2.0, 3.0], Z=3.976, P<0.001), work (1.0 [1.0, 2.0] vs. 2.0 [1.0, 2.0], Z=2.279, P=0.023] and daily life (1.7 [1.3, 2.0] vs. 2.0 [2.0, 2.3], Z=3.950, P<0.001) were better in the PG-DT than the PG-GT group. Patients in the PG-GT group scored better than those in the PG-DT group for somatic symptoms, such as anal evacuation (3.0 [2.0, 4.0] vs. 3.5 [2.0, 5.0], Z=2.345, P=0.019). There were no significant differences in hemoglobin, serum albumin, serum total protein, or weight loss 1 year postoperatively between the two groups (all P>0.05). Conclusions: The safety of double tract anastomosis for proximal gastric cancer is comparable to that of gastric tube surgery. Compared with gastric tube surgery, double tract anastomosis achieves less esophageal reflux and better quality of life, making it a preferable surgical procedure for proximal gastric cancer.

Gastric remnant cancer and long-term survival in Central Norway 2001 to 2016 - A population-based study.

INTRODUCTION: Gastric remnant cancer (GRC) has been defined as a distinct clinical entity and is reported to account for 1-8% of all gastric cancers. We aimed to characterize GRC patients and assess survival in a Western population. METHODS: Retrospective population-based cohort study including 1217 patients diagnosed with gastric adenocarcinoma in Central Norway 2001-2016. GRCs (n = 78) defined as adenocarcinomas arising in the residual stomach after distal gastrectomy were compared to non-GRC (n = 1139) and to proximal non-GRC (n = 595). RESULTS: 78 (6.4 %) gastric cancers were GRC. The annual number and proportion of GRC declined during the study period (p = 0.003). Median latency from distal gastrectomy to GRC diagnosis was 37.6 years (15.7-68.0) and previous Billroth II reconstruction was most common (87.7%). Compared to controls, GRC patients were more frequently males (83.3%), diagnosed in earlier TNM stages and were older at diagnosis. A smaller proportion of GRC patients received perioperative or palliative chemotherapy, but the R0/R1resection rate of 41.0% was no different from non-GRC patients. Overall median survival for GRC patients irrespective of treatment was 7.0 months, which did not differ from non-GRCs or proximal non-GRC. In multivariate analyses TNM stage and age were independently associated with mortality, whereas GRC per se was not. CONCLUSIONS: Numbers of GRCs declined during the study period, but the latency between distal gastrectomy and GRC diagnosis was long. GRC patients were more frequently male and older than other gastric cancer patients. GRC was not independently associated with survival after adjusting for TNM stage and tumor location.

[Preliminary exploration of modified side overlap with fundoplication by Yamashita (mSOFY) anastomosis technique in laparoscopic proximal gastrectomy].

Objective: To discuss the feasibility and safety of modified side overlap with fundoplication by Yamashita (mSOFY) in laparoscopic proximal gastrectomy. Methods: Using the method of descriptive case series study, the clinical data of 9 patients with upper gastric cancer who successfully performed mSOFY anastomosis from March 2022 to October 2022 in the Affiliated Huaian No.1 People's Hospital of Nanjing Medical University were retrospectively analyzed.The reconstruction steps of mSOFY anastomosis are as follows: (1) Make a small incision on the right side of the esophageal stump and in front of the anterior wall of the gastric stump; (2) The 45mm linear cutting stapler is placed into the preset anastomosis of the esophagus and the remnant stomach, and the esophagus is rotated 90° counterclockwise along the axis, so that the right wall of the esophagus is anastomosed with the remnant stomach, and the stomach wall is sutured to the left side of the esophagus; (3) The common opening of esophagus and remnant stomach was sutured with inverted suture; (4)Suture the left and lower sides of the esophagus with the remnant stomach to make the esophagus flat against the stomach wall; (5) Open the sutured common opening: due to the pressure of the false dome, the posterior wall of the lower esophageal segment was compressed into a valve-like structure. We mainly observing the postoperative reflux and nutritional improvement of the patients, and recording the intraoperative situation and postoperative complications. Results: Nine patients with upper gastric cancer who completed laparoscopic proximal gastrectomy (mSOFY anastomosis) did not have conversion to laparotomy or intraoperative / postoperative complications. The operation time was (169.4±10.4) minutes, the anastomotic reconstruction time was (51.7±7.1) minutes, the intraoperative bleeding volume was (98.9±43.4) ml, and the number of lymph nodes dissected was (27.2±6.7). The patient recovered well after operation, without any complaints related to reflux esophagitis. Postoperative gastrointestinal radiography showed that the anastomosis was smooth, without stenosis and leakage. The serum albumin [(41.6±3.4) L vs. (39.9±2.6) L], prealbumin [(211.3±38.6) mg/L vs. (205.3±36.0) mg/L], and hemoglobin levels [(126.7±13.2) g/L vs. (121.0±9.7) g/L] of patients before and one month after surgery have no statistically significant differences (all P>0.05). Conclusion: mSOFY anastomosis can be used as one of the safe and feasible reconstruction methods in laparoscopic proximal gastrectomy.

Robotic Splenic Vessels Preserving Distal Pancreatectomy in a Post-Distal Gastrectomy Patient.

BACKGROUND: The optimal procedure during distal pancreatectomy (DP) for patients who have undergone distal gastrectomy (DG) remains unclear. Several papers on remnant gastric ischemia have reported that the preserved splenic vessels are essential for the proximal remnant stomach.1-4 We evaluated the outcomes of DP for post-DG patients in our hospital and introduced robotic splenic vessels preserving DP (R-SPDP). METHODS: Postoperative short-term outcomes of DP for post-DG patients during 2014 and 2021 were evaluated. Next, R-SPDP was performed for a post-DG patient with the intention of preserving the remnant stomach safely. The double bipolar method was used to dissect the adhesions around the splenic vessels.5,6 The splenic artery was clamped at the root side to prevent bleeding.7 All short gastric arteries and veins, which were the main feeders of the remnant stomach, were preserved and resection was completed. After resection, the indocyanine green (ICG) fluorescence angiography confirmed blood flow in the short gastric arteries and veins and good return blood flow to the splenic vein.8 RESULTS: Of four patients (50.0%, of 8 DP patients) in whom the remnant stomach was preserved, one conventional DP case had poor ICG perfusion and presented with remnant stomach ischemia postoperatively. The R-SPDP case with good ICG perfusion had a total operation time of 371 minutes and intraoperative blood loss of 10 mL. The oral diet was started on postoperative Day 3, and the postoperative course was uneventful. CONCLUSIONS: R-SPDP can be a good option for post-DG patients to preserve the remnant stomach safely.

The epigenetic modifier lysine methyltransferase 2C is frequently mutated in gastric remnant carcinoma.

Gastric remnant carcinoma (GRC), which occurs in the stomach after partial gastrectomy, is a rare and aggressive form of gastric adenocarcinoma (GAC). Comprehensive profiling of genomic mutations in GRC could provide the basis for elucidating the origin and characteristics of this cancer. Herein, whole-exome sequencing (WES) was performed on 36 matched tumor-normal samples from patients with GRC and identified recurrent mutations in epigenetic modifiers, notably KMT2C, ARID1A, NSD1, and KMT2D, in 61.11% of cases. Mutational signature analysis revealed a low frequency of microsatellite instability (MSI) in GRC, which was further identified by MSIsensor, MSI-polymerase chain reaction, and immunohistochemistry analysis. Comparative analysis demonstrated that GRC had a distinct mutation spectrum compared to that of GAC in The Cancer Genome Atlas samples, with a significantly higher mutation rate of KMT2C. Targeted deep sequencing (Target-seq) of an additional 25 paired tumor-normal samples verified the high mutation frequency (48%) of KMT2C in GRC. KMT2C mutations correlated with poor overall survival in both WES and Target-seq cohorts and were independent prognosticators in GRC. In addition, KMT2C mutations were positively correlated with favorable outcomes in immune checkpoint inhibitor-treated pan-cancer patients and associated with higher intratumoral CD3+ , CD8+ tumor-infiltrating lymphocyte counts, and PD-L1 expression in GRC samples (p = 0.018, 0.092, 0.047, 0.010, and 0.034, respectively). Our dataset provides a platform for information and knowledge mining of the genomic characteristics of GRC and helps to frame new therapeutic approaches for this disease.

PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy: study protocol for the PYNI-GAREREO phase III randomized controlled trial.

BACKGROUND: After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying. METHODS: The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively. DISCUSSION: We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346 .

Surgical treatment of gastric stump carcinoma after Whipple procedure: A case report.

RATIONALE: Gastric stump carcinoma (GSC) is very exceptional and little known after Whipple procedure, and its diagnosis and treatment are extremely difficult to handle. PATIENT CONCERNS: The patient, a 68-year-old man, visited our hospital's General surgery outpatient clinic complaining of upper abdominal pain that had been bothering him for half a month. The endoscopy revealed lesions in the stomach residual, and the pathological results suggested adenocarcinoma. The patient underwent Whipple procedure for periampullary adenocarcinoma in the 4th year ago. DIAGNOSES: The final diagnosis was gastric adenocarcinoma and its pathological stage was Ⅱ A (T3N0M0). INTERVENTIONS: The patient underwent stump gastrectomy and end-to-side esophagojejunostomy (Roux-en-Y reconstruction). OUTCOMES: The operation went smoothly and the patient recovered well with only mild bloating and nausea, and the symptoms completely disappeared during the hospital stay. LESSONS: The development of GSC several years after Whipple procedure is uncommon. This is the first case from China that has received international attention. Early diagnosis is crucial. Surgery is considered to be the most effective treatment for GSC after Whipple procedure if long-term survival is possible and surgical risks are controllable.

Rational Gastric Conduit Stump Closure Method Using Endo GIA Radial Reload in End-to-Side Anastomosis of the Esophagogastric Conduit.

Background: The lack of tension at the anastomosis site and the blood flow of the gastric conduit are important to prevent anastomotic leakage in the anastomosis of the esophagogastric conduit. This study reports a gastric conduit stump closure method using Endo GIA™ Radial Reload in end-to-side anastomosis of the esophagogastric conduit, especially focusing on blood flow. Methods: A 4-cm conduit was created to ensure an intramural vascular network. The gastric conduit was elevated to the neck through the posterior mediastinal route, and end-to-side anastomosis of the esophagus and gastric conduit was performed using a circular stapler. Closure of the gastric stump with an Endo GIA Radial Reload was performed 2 cm proximal to the anastomosis on the end side of the esophagogastric conduit. The lesser curvature of the stump of the gastric conduit is the most frequent site of anastomotic leakage as it has the least blood flow, and the pressure is highest when the pressure inside the gastric conduit increases. Therefore, the gastric conduit stump was closed using the Endo GIA Radial Reload to resect the intersection of the gastric stump and lesser curvature from which the gastric conduit was created. The gastric conduit stump is gently curved; therefore, the pressure applied to the gastric conduit stump could be dispersed when the intragastric pressure increases. Results: No anastomotic leakage was observed among the 21 patients who underwent this method. Conclusion: This method is a novel anastomosis method to prevent anastomotic leakage in an end-to-side anastomosis of the esophagogastric conduit.

Simultaneous robotic distal gastrectomy and distal pancreatectomy: Avoiding total gastrectomy using indocyanine green fluorescence imaging.

Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78-year-old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.

Gastrointestinal Stromal Tumor in the Excluded Gastric Remnant After Roux-en-Y Gastric Bypass.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the GI tract. Despite this, they rarely occur, accounting for only 1% to 3% of all gastrointestinal tumors. This report describes a 53-year-old female patient with surgical history of Roux-en-Y gastric bypass (RYGB) who presented with right upper quadrant abdominal pain. CT imaging revealed a large 20 × 12 × 16 cm mass in the excluded stomach remnant. Ultrasound-guided biopsy confirmed this mass to be a GIST. The patient was treated surgically with exploratory laparotomy with distal pancreatectomy, partial colectomy, partial gastrectomy, and splenectomy. There are currently only 3 known reported cases of GISTs after RYGB.