Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy.

BACKGROUND: Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. METHODS: This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. RESULTS: The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. CONCLUSION: IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Effect of the postural transition in minimally invasive esophagectomy: a propensity score matching analysis.

BACKGROUND: The advantages of prone position in minimally invasive esophagectomy have not been well studied. This study aimed to investigate the safety and feasibility of a transition from the left lateral decubitus position to the prone position for thoracic procedures in minimally invasive esophagectomy. METHODS: We retrospectively analyzed patients with thoracic esophageal carcinomas who underwent thoracoscopic esophagectomy and laparoscopic gastric mobilization between January 2015 and December 2019. The left decubitus and prone positions were analyzed using propensity score-matched pairs for the baseline characteristics, morbidity, and survival. RESULTS: A total of 114 consecutive patients were included in this study; 90 (78.9%) were male and the median age was 67.2 years old. Of these patients, 39 and 75 underwent left decubitus and prone esophagectomy, respectively. Prone esophagectomy was associated with a lower incidence of pneumonia than that performed in the decubitus position (12.5% vs. 37.5%, p = 0.0187). With respect to the long-term outcomes, there were no significant differences between the 2 groups. The 4-year overall and relapse-free survival rates for prone and decubitus esophagectomy were 73.8% and 73.2%, and 84.4% and 71.8%, respectively (p = 0.9899 and 0.6751, respectively). Prone esophagectomy yielded a shorter operative time (total: 528 [485-579] min vs. 581 [555-610] min, p < 0.0022; thoracic section: 243 [229-271] min vs. 292 [274-309] min, p < 0.0001), less bleeding in the thoracic procedures (0 [0-10] mL vs. 70 [20-138] mL, p < 0.0001), a shorter length of postoperative hospital stay (19 [15-23] vs. 30 [21-46] days, p = 0.0002), and a lower total hospital charge (30,046 [28,175-32,660] US dollars vs. 36,396 [31,533-41,180] US dollars, p < 0.0001). CONCLUSIONS: Transition into the prone position in minimally invasive esophagectomy is feasible with adequate postoperative and oncological safety and economical in esophageal cancer surgery.

Head Injury Assessment in the Elite Level Rugby Union in Japan: Review of 3 Seasons.

Head Injury Assessment (HIA) is the screening tool for head injury during a rugby game. The purpose of this study was to investigate the epidemiology of HIA in the Japan Rugby Top League (JRTL). The incidences of HIA, defined concussion (per 1,000 player-hours) and repeated concussions were evaluated in three seasons (2016-17, 2017-18, 2018-19; total 360 games). The HIA incidence rates were 12.7 (95% confidence interval 9.5-15.9), 20.8 (16.8-24.9), and 25.0 (20.5-29.5) in each season. HIA-1 criteria 2, which is applied for suspected concussion cases, was performed for 46 cases in the 2016-17 season, 81 cases in the 2017-18 season, and 88 cases in the 2018-19 season. The concussion incidence rates were significantly greater in the 2017-18 season (9.6/1000 player-hours, 95% confidence interval 6.8-12.4) and the 2018-19 season (14.4, 11-17.8) compared to the 2016-17 season (4.8, 2.8-6.8). The number of repeated concussion cases in the same season was 1 in the 2016-17 season and 4 in both the 2017-18 and 2018-19 seasons. This study confirmed significantly higher HIA and concussion incidence rates over time. Although the HIA system might have been established in the three seasons in JRTL, comprehensive management needs to be improved to prevent repeated concussions.

A multicenter non-randomized phase III study of sentinel node navigation surgery for early gastric cancer.

This prospective multicenter non-randomized phase III study aims to evaluate the long-term outcome of sentinel node navigation surgery for early gastric cancer compared with conventional distal or total gastrectomy. Clinically diagnosed primary T1N0M0 gastric cancer patients with a single lesion (≤40 mm) and without previous endoscopic treatment will be enrolled in this study. Sentinel nodes are identified by dye and radioisotope tracers and are subjected to intraoperative rapid pathology. For patients with negative sentinel node metastasis, individualized surgery consisting of limited stomach resection and sentinel node basin dissection is performed, while standard gastrectomy with D2 lymph node dissection is employed for the positive sentinel node patients. A total of 225 patients will be accrued from 13 hospitals that have experience in sentinel node mapping. The primary endpoint is 5-year relapse-free survival. The secondary endpoints are overall survival, sentinel node detection rate, diagnostic accuracy for sentinel node, distribution of sentinel nodes and metastatic sentinel node/non-sentinel node, and postoperative quality of life.

Short- and long-term outcomes of laparoscopic versus open gastrectomy for locally advanced gastric cancer following neoadjuvant chemotherapy.

BACKGROUND: This study aimed to investigate the short- and long-term outcomes of laparoscopic gastrectomy (LG) in patients with advanced gastric cancer following neoadjuvant chemotherapy (NAC) to determine its safety and feasibility. METHODS: We retrospectively investigated 51 patients who underwent gastrectomy for locally advanced gastric cancer [cT3-4/N1-3 or macroscopic type 3 (> 80 mm) or type 4] following NAC between November 2009 and January 2018. After excluding two patients who underwent palliative surgery due to peritoneal dissemination, 49 patients were ultimately selected for this cohort study. The patients were then divided into the LG group and open gastrectomy (OG) group, after which the clinicopathological characteristics as well as short- and long-term outcomes were examined. RESULTS: Compared with the OG group, the LG group demonstrated a significantly lower amount of intraoperative blood loss and a shorter hospital stay. The overall complication rates were 10% (2 of 20 patients) and 24% (7 of 29 patients) in the LG and OG groups (P = 0.277), respectively. No significant differences in 5-year disease-free (LG 44.4% vs. OG 53.3%; P = 0.382) or overall survival rates (LG 46.9% vs. OG 54.0%; P = 0.422) were observed between the groups. Multivariate analysis revealed that the surgical procedure (LG vs. OG) was not an independent risk factor for disease-free (P = 0.645) or overall survival (P = 0.489). CONCLUSIONS: LG may be a potential therapeutic option for patients with gastric cancer following NAC considering its high success rates and acceptable short- and long-term outcomes.

Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance.

BACKGROUND: Laparoscopic Heller-myotomy with Dor-fundoplication (LHD) is the standard surgical treatment for achalasia; however, surgical outcomes over a period greater than 10 years have not been well-explored. The objective of this study was to evaluate the long-term outcomes of LHD for achalasia based on a single-center experience. METHODS: Patients who underwent LHD between 1994 and 2019 were included. Of these, we excluded patients who had undergone foregut surgery or whose follow-up data were unavailable. Esophagogastroduodenoscopy (EGD) findings and postoperative persistent and/or recurrent symptoms had been assessed annually. Disease-free rates were calculated using Kaplan-Meier analysis. RESULTS: A total of 530 patients (mean age 45.0 years with 267 men) were included. The median follow-up period was 50.5 months. More than 10 years' data were available in 78 patients (14.7%). The cumulative rates of freedom from dysphagia, vomiting, chest pain, and Eckardt score > 3 at 10 years after LHD were 80.1%, 97.5%, 96.3%, and 73.5%, respectively. Probability of esophagitis during 10 years after surgery was 34.4% of patients based on Kaplan-Meier estimation. Approximately 3/4th of patients who had post-LHD esophagitis showed mild esophagitis of Los Angeles classification grade A. Fifteen patients (2.8%) were required a revision of primary LHD. Six patients (1.2%) developed esophageal cancer with an incidence was as high as 219.8/100,000 person-year. All patients with esophageal cancer were found to have early stage tumors that were successfully resected. CONCLUSIONS: Symptomatic relief post-LHD lasted for over 10 years. The incidence rate of esophageal cancer was high. Regular EGD surveillance seems to be helpful for early detection of esophageal cancer early.

Prognostic Significance of Preoperative Osteopenia in Patients Undergoing Esophagectomy for Esophageal Cancer.

BACKGROUND: Osteopenia, which exhibits low bone mineral density (BMD), has been linked to sarcopenia and recently reported as a prognostic factor in various cancers. However, the prognostic significance of osteopenia in esophageal cancer remains unclear. Hence, this study aimed to clarify the impact of osteopenia on the prognosis of patients undergoing esophagectomy for esophageal cancer. METHODS: We included 229 patients who underwent esophagectomy. BMD was calculated as the average pixel density (Hounsfield unit) within a circle in midvertebral core at the 11th thoracic vertebra on preoperative computed tomography. We then divided the patients into the Osteopenia group (n = 159) and the Non-Osteopenia group (n = 70) according to the optimal cutoff value obtained from the receiver operating characteristic curve. Their clinicopathological data, prognosis, and recurrence were analyzed. RESULTS: The mean age was significantly older in the Osteopenia group (p = 0.047). The Osteopenia group had significantly worse overall survival (OS) and relapse-free survival (RFS) than the Non-Osteopenia group (p = 0.001 and p = 0.012, respectively). Multivariate analysis revealed osteopenia was an independent prognostic factor for OS (p < 0.001; hazard ratio [HR], 2.243; 95% confidence interval [CI], 1.422-3.538) and RFS (p = 0.008; HR, 1.739; 95% CI, 1.154-2.620). In logistic regression model, advanced age and cStage III-IV were independent risk factors for preoperative osteopenia. CONCLUSIONS: Preoperative osteopenia is associated with poor survival and recurrence in patients undergoing esophagectomy for esophageal cancer.

What are the important prognostic factors in gastric cancer with positive duodenal margins? A multi-institutional analysis.

PURPOSE: Positive margins are reported in from 4.8 to 9.5% of all gastric cancer surgeries and they have a negative impact on the overall survival. Few cases with positive duodenal margins have been included in previous studies regarding the prognosis. METHODS: This multi-institutional retrospective study included 115 gastric cancer patients with positive duodenal margins following gastrectomy between January 2002 and December 2017. The association between clinicopathological factors and the overall survival was evaluated by univariate and multivariate analyses. RESULTS: The three-year overall survival was 22% and the median survival was 13 months. A multivariate analysis found that distant metastasis, no postoperative chemotherapy, and non-Type 4 disease were significantly associated with a poor survival. Patients without distant metastasis who received postoperative chemotherapy had a 3-year overall survival of 56% and a median survival of 44 months. CONCLUSION: The patients who underwent post-operative chemotherapy showed a significantly better OS compared with those who did not undergo post-operative chemotherapy, regardless of the existence of distant metastasis. Postoperative chemotherapy may, therefore, improve the prognosis of surgically treated gastric cancer patients with positive duodenal margins.

Prediction of Severe Cisplatin-Induced Neutropenia Using Serum Albumin Concentration-A Retrospective Study.

BACKGROUND: Cisplatin that is used in the treatment of gastric cancer not only has gastrointestinal side effects but also has a high serum protein-bound fraction. Reduction of serum albumin concentration may cause increase the risk of cisplatin- induced neutropenia. Hence, alteration of serum albumin concentration poses a major safety issue during anticancer therapy. METHODS: For gastric cancer patients who received cisplatin plus S-1 therapy, we investigated the relationship between the serum albumin concentration before cisplatin administration in the treatment course during which the neutrophil count reached nadir and the neutrophil count fluctuation after cisplatin administration. RESULTS: In the grade 3-4 neutropenia and grade 0-2 neutropenia groups, the mean serum albumin concentration before cisplatin administration was 3.39±0.60 and 3.85±0.59 g/dL, respectively; in the former group were significantly lower than in the latter group(p=0.006). Lower serum albumin concentrations before cisplatin administration were significantly correlated with a decrease in neutrophil count after cisplatin administration(r=0.463, p<0.001). According to the receiver operating characteristic curve analysis, patients with serum albumin concentrations below 3.25 g/dL before cisplatin administration exhibited a significantly higher incidence of grade 3-4 neutropenia(odds ratio: 4.33). CONCLUSIONS: Decreased serum albumin levels were found to be strongly associated with the prediction of the development of severe neutropenia. Our findings emphasize serum albumin concentration needs to be evaluated before each administration of cisplatin.

Feasibility of enhanced recovery protocol in minimally invasive McKeown esophagectomy.

BACKGROUND: Implementation of enhanced recovery after surgery has generally been applied to gastrointestinal surgeries; however, few studies have investigated minimally invasive McKeown esophagectomy. In this study, we aimed to evaluate the safety and feasibility of an enhanced recovery protocol after minimally invasive McKeown esophagectomy. METHODS: Data were collected between January 2015 and April 2020 for patients who underwent esophagectomy. Of these patients, those who underwent minimally invasive McKeown esophagectomy was selected for the investigation. Perioperative outcomes and nutritional index were compared using propensity score matching between the conventional group and the enhanced recovery group. RESULTS: A total of 119 patients were enrolled in this study. Of these, 73 and 46 were treated with conventional and enhanced recovery protocol, respectively. Forty-two pairs were matched in two groups. The enhanced recovery group showed a lower rate of pulmonary complications (9.5% vs. 28.5%, p = 0.0235), abdominal dysfunctions (16.7% vs. 42.9%, p = 0.0078), and shorter hospital stay as compared with the conventional group (17.5 days vs. 23 days, p = 0.0034). The loss of body weight (6.3% vs. 7.7%, p = 0.0065) and body mass index (5.6% vs. 8.1%, p = 0.0017) were significantly lower in the enhanced recovery group than in the conventional group. In contrast, nutritional biochemistry data did not differ significantly between the two groups. CONCLUSIONS: This study shows that the promotion of an enhanced recovery protocol in minimally invasive McKeown esophagectomy maintains nutritional status without increasing postoperative complications.

Sentinel node mapping for post-endoscopic resection gastric cancer: multicenter retrospective cohort study in Japan.

BACKGROUND: Standard gastrectomy with systematic lymphadenectomy as an additional surgery after endoscopic resection (ER) causes a deterioration in long-term quality of life. If the sentinel lymph node (SN) basin concept can be applied in post-ER gastric cancer, minimal surgery can be applied without reducing the curability. This retrospective multicenter cohort study aimed to verify the validity of the SN basin concept in post-ER gastric cancer. PATIENTS AND METHODS: Individual data of 132 patients who underwent SN mapping after ER were collected from 8 university hospitals in Japan from 2001 to 2016. Tracers were injected endoscopically in the submucosal layer at four sites around the post-ER scar. We compared the SN basin distribution of post-ER gastric cancer with that of 275 patients with non-ER gastric cancer. RESULTS: Two cases of SN were unidentified, both involving a single tracer (SN detection rate: 98.5%). Nine cases (6.8%) of lymph node metastasis were found, of which eight had a metastatic lymph node within the SNs and one had a non-SN metastasis within the SN basin. The diagnostic sensitivity of SN mapping for lymph node metastasis was 88.9% in post-ER group and 95.7% in non-ER group (P = 0.490); the accuracy was 99.2% and 99.6% (P = 0.539), respectively. Regarding the SN basin, no significant intergroup differences were found regardless of the primary tumor location. CONCLUSIONS: Our findings clarified the feasibility of SN mapping based on the SN basin concept in patients with gastric cancer who previously underwent ER.

[Effect of Hypoalbuminemia on Severe Neutropenia Induced by Paclitaxel Monotherapy and Paclitaxel plus Ramucirumab Combination Therapy in Patients with Gastric Cancer].

Hypoalbuminemia is often observed in patients receiving chemotherapy for gastric cancer. The risk of hematologic toxicity is increased by the pharmacokinetic alteration of paclitaxel(PTX)owing to high serum protein binding in patients with hypoalbuminemia. Here, we examined the relationshipbetween the frequency of GradeB3 neutropenia and serum albumin concentration in 30 patients receiving PTX monotherapy, and 29 patients receiving PTX plus ramucirumab(RAM)combination therapy-a second-line treatment for advanced/recurrent gastric cancer. The number of patients who developed GradeB3 neutropenia was 8(27%)and 14(48%)of those who received monotherapy and combination therapy, respectively, with mean serum albumin concentrations of 3.31 g/dL and 3.15 g/dL, respectively. Serum albumin concentrations were significantly lower in the GradeB3 neutropenia group than in the non-GradeB3 neutropenia group in both regimens. When the serum albumin concentration of patients receiving PTX or PTX plus RAM was below the cut-off values of 3.75 g/dL and 3.45 g/dL, respectively, the odds ratio of GradeB3 neutropenia was 12.25 and 7.33, respectively. Hypoalbuminemia was associated with the development of chemotherapy-induced GradeB3 neutropenia, in patients with gastric cancer treated with either PTX monotherapy or PTX plus RAM combination therapy. Therefore, not only neutrophils but also serum albumin concentration should be monitored during chemotherapy.

A randomized phase II multicenter trial to explore efficacy of weekly intraperitoneal in comparison with intravenous paclitaxel administered immediately after gastrectomy to the patients with high risk of peritoneal recurrence: final results of the INPACT trial.

BACKGROUND: Intraperitoneal administration of paclitaxel had been considered a promising option to treat peritoneal metastasis, the most frequent pattern of recurrence in gastric cancer after D2 gastrectomy, but its safety and efficacy after gastrectomy had not been fully explored. METHODS: A phase II randomized comparison of postoperative intraperitoneal (IP) vs. intravenous (IV) paclitaxel was conducted. Patients with resectable gastric linitis plastica, cancer with minimal amount of peritoneal deposits (P1), or cancer positive for the peritoneal washing cytology (CY1) were eligible. After intraoperative confirmation of the above disease status and of resectability, patients were randomized to be treated either by the IP therapy (paclitaxel 60 mg/m2 delivered intraperitoneally on days 0, 14, 21, 28, 42, 49, and 56) or the IV therapy (80 mg/m2 administered intravenously using the identical schedule) before receiving further treatments with evidence-based systemic chemotherapy. The primary endpoint was 2-year survival rate. RESULTS: Of the 86 patients who were randomized intraoperatively, 83 who actually started the protocol treatment were eligible for analysis (n = 39, IP group; n = 44, IV group). The 2-year survival rate of the IP and IV groups was 64.1% (95% CI 47.9-76.9) and 72.3% (95% CI 56.3-83.2%), respectively (p = 0.5731). The IP treatment did not confer significant overall or progression-free survival benefits, and was associated with particularly poor performance in patients with residual disease, including the CY1 P0 population. CONCLUSIONS: We were unable to prove superiority of the IP paclitaxel over IV paclitaxel delivered after surgery to control advanced gastric cancer with high risk of peritoneal recurrence.

Sentinel Node Navigation Surgery for Early Gastric Cancer: Analysis of Factors Which Affect Direction of Lymphatic Drainage.

BACKGROUND AND PURPOSE: We started performing sentinel node navigation surgery (SNNS) for patients with early gastric cancer (EGC) using infrared ray electronic endoscopy (IREE) with indocyanine green injection from year 2000. The EGCs usually have complex lymphatic drainage, unidirectional or multidirectional lymphatic flow. In this study, we investigated and clarified factors that affect the direction of gastric lymphatic drainage. PATIENTS AND METHOD: Consecutive 60 patients with EGC who underwent SNNS by IREE from year 2006 to 2014 were enrolled to this study. Patients' age, gender, location of tumors, operative method, previous treatment by endoscopic submucosal dissection (ESD), presence of pathological ulcerative scar and maximum tumor diameter were enrolled as parameters which may affect direction of lymphatic drainage and analyzed. RESULT: Bivariate analysis demonstrated that the presence of pathological ulcerative scar (P = 0.01), tumor location (g.c vs. a.w vs. p.w vs. l.c, P = 0.01), and maxim tumor diameter (P = 0.0003) were relevant to direction of gastric lymphatic drainage. Multivariate analysis showed that tumor location (g.c/a.w/p.w vs. l.c, odds ratio 8.227, P = 0.011) and the maximum tumor diameter (odds ratio 1.057, P = 0.037) are independent factors that affect direction of gastric lymphatic flow. Of tumors, 78% located at lesser curvature had unidirectional lymphatic drainage, and 93% of tumors whose diameter was 40 mm and more had multidirectional lymphatic drainage. CONCLUSION: Our investigation revealed that the tumor location and tumor diameter were the key factors which affect the direction of lymphatic drainage, which is useful fact to understand the complexity of gastric lymphatic drainage.

Association of level of anastomosis and anastomotic leak after esophagectomy in anterior mediastinal reconstruction.

AIM: The purpose of this study was to investigate modifiable predisposing factors associated with anastomotic leak in the anterior mediastinal (AM) reconstruction route. METHODS: We reviewed the data on 154 patients who underwent esophagectomy and gastric tube reconstruction using the AM route between 2008 and 2016. The data included computed tomography (CT) scans with sagittal reconstruction of the thoracic section. The level of the esophagogastric anastomosis (LEA) and pretracheal distance (PTD) was measured from sagittal reconstructed CT images. Vascularization of the gastric tube was evaluated by postoperative endoscopy. Variables associated with anastomotic leak were determined using univariate and multivariate analyses. RESULTS: Anastomotic leak developed in 13 patients (8%). The cut-off level at which the anastomosis was less likely to develop a leak, as determined by Chi-square tests, was 1.5 cm for LEA and 1.3 cm for PTD. On univariate analysis, the factors that were significantly associated with the risk of anastomotic leak included diabetes, hand-sewn anastomosis, the LEA ≥ 1.5 cm, and severe mucosal degeneration. On multivariate analysis, diabetes (OR 4.7, 95% CI 1.29-17.2), LEA ≥ 1.5 cm (OR 20.1, 95% CI 3.15-128), and severe mucosal degeneration (OR 7.2, 95% CI 1.42-36.8) were found to be statistically significant independent risk factors. CONCLUSION: Use of the AM route to place the cervical anastomosis within 1.5 cm above the suprasternal notch might avoid excessive pressure on the gastric tube from the surrounding structures, resulting in a reduction in the risk of an anastomotic leak.

Laparoscopic sentinel node navigation surgery for early gastric cancer: a prospective multicenter trial.

BACKGROUND: Prospective multicenter trials have shown the feasibility of sentinel node (SN) navigation surgery using a dual tracer of dye and radioisotope for early gastric cancer. However, comparable trials using the indocyanine green (ICG) and the infrared ray laparoscopic system (IRLS) have not been reported. On the basis of our cohort studies, we assumed that the ICG imaging with the IRLS is as effective as the dual tracer in detecting SNs. Therefore, we conducted a prospective multicenter trial to assess the effectiveness and generalizability of the infrared ICG technique in patients with early gastric cancer. PATIENTS AND METHODS: Patients with previously untreated cT1 gastric adenocarcinomas less than 4 cm in gross diameter were eligible for inclusion in this study. SN mapping was performed by using ICG combined with IRLS technique. Following biopsy of the identified SNs, D2 or modified D2 laparoscopic gastrectomy was performed according to the current Japanese Gastric Cancer Association guidelines. RESULTS: Among the 47 patients who gave written informed consent, 44 were eligible from the surgical findings, for whom SN biopsy was performed. The detection rate of the lymphatic basin by the ICG with IRLS was 100% (44/44). The accuracy was also 100% (7/7) for detecting metastatic lymph node, which was verified on the permanent pathologic examination. Following the median follow-up of 114 months (range, 60 to 120 months), no recurrence (0/40) was observed. Although the number of patients was unequally distributed among the hospitals participating in the trial, the detection rates of SNs in low-volume hospitals were comparable to those in high-volume hospitals. Consequently, there was no learning curve in this trial. CONCLUSION: The infrared ICG imaging accurately detected the lymphatic basin and SNs with occult metastasis in SN-navigated gastrectomy for gastric cancer. This method was feasible even for low-volume surgeons and hospitals.

Comparison of laparoscopic Nissen and Toupet fundoplication using a propensity score matching analysis.

PURPOSE: Laparoscopic fundoplication (LF) has become a standard operative procedure for GERD-related diseases in Japan, although meta-analyses have mainly evaluated findings from Western countries. The propensity score matching method was used to compare and investigate the treatment outcomes of two fundoplication procedures (the Nissen and Toupet methods). METHODS: Among 474 patients who underwent initial LF from December 1994 to April 2016, we extracted 401 cases (Nissen: 92 cases, Toupet: 309 cases), excluding 73 patients in whom follow-up was insufficient. We then matched 126 of these patients (63 per group). RESULTS: The esophageal acid reflux time (%) was 12.2:2.8, being higher in the Nissen group than in the Toupet group (p < 0.001). Regarding the surgical outcome, the amount of bleeding was higher in the Nissen group (p = 0.001), and the number of hospitalization days following surgery was longer (p = 0.003). Furthermore, a significantly rate of postoperative difficulty in swallowing (%) was observed in the Nissen group, at 13:0 (p = 0.004). The recurrence rate (%) was 8:3, with no difference between the two groups (p = 0.243). CONCLUSIONS: Although there was no marked difference in the recurrence rate between the two procedures, postoperative dysphagia was observed at a higher frequency with the Nissen method than the Toupet method.

Impaired Gastrointestinal Function Affects Symptoms and Alimentary Status in Patients After Gastrectomy.

BACKGROUND: Postgastrectomy syndrome (PGS) remains a common complication after gastrectomy that affects patients' quality of life. Although impaired gastrointestinal (GI) function by gastrectomy procedures is thought to be the cause, the precise pathophysiology of PGS is yet to be clarified. AIM: The aim of this study was to investigate relationships between GI function and various symptoms or alimentary status in patients after gastrectomy. METHODS: Fifty-one patients who underwent total or distal gastrectomy at least 1 year previously were studied. All patients replied to a questionnaire that asked presence of symptoms (esophageal reflux, nausea, abdominal pain, early satiation, diarrhea, early dumping general, early dumping abdominal, and late dumping symptoms) and alimentary status (change in body weight, food intake per meal, frequency of meals per day). They also underwent assessment of GI function consisting of gastric emptying study by 13C-acetate breath test to examine reservoir capacity and gastric emptying, and water load drink test to evaluate tolerance to volume loading (TVL). The relationships between GI function and each symptom or alimentary status were examined. RESULTS: The patients with nausea and early dumping general symptoms had significantly smaller reservoir capacity*, the patients with diarrhea and early dumping general symptoms had significantly faster gastric emptying*, and the patients with early satiation and early dumping abdominal symptoms had significantly impaired TVL*. Significant correlations were identified between TVL and body weight changes* or food intake per meal* (* p < 0.05). CONCLUSION: Impaired postoperative GI function was closely related to symptoms or worse alimentary status.

Specific Features of Dumping Syndrome after Various Types of Gastrectomy as Assessed by a Newly Developed Integrated Questionnaire, the PGSAS-45.

AIM: Dumping syndrome is a well-known adverse outcome after gastrectomy, but the precise clinical features have not been described. The aim of this study was to examine global aspects of dumping syndrome and to explore factors affecting the intensity of dumping syndrome in a large cohort using a newly developed integrated questionnaire, the Post-Gastrectomy Syndrome Assessment Scale (PGSAS)-45. METHODS: Eligible questionnaires retrieved from 2,368 patients after 6 types of gastrectomy were analyzed. The incidence, intensity and number of symptoms of early general, early abdominal and late dumping syndrome were examined across various types of gastrectomy, and clinical factors affecting the intensity of each category of dumping syndrome were identified by multiple regression analysis. RESULTS: Dumping syndromes occurred most frequently and strongly in patients who underwent total gastrectomy with Roux-en-Y (TGRY), followed by proximal gastrectomy (PG), distal gastrectomy with Billroth-I, distal gastrectomy with Roux-en-Y, pylorus-preserving gastrectomy (PPG) and local resection (LR), in that order. Significant positive correlations among different categories of dumping syndromes were observed. TGRY, female sex, younger age, division of the celiac branch of the vagus nerve, PG and shorter postoperative period were independently related to worse dumping syndrome. CONCLUSIONS: Dumping syndromes were most common after TGRY and least common after PPG and LR among the various gastrectomy procedures. Type of gastrectomy and several clinical factors were related to the intensity of dumping syndrome. PGSAS-45 could offer a useful tool for evaluating dumping syndrome after gastrectomy.