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BACKGROUND: Scarce data are available on the characteristics of postoperative organ failure (POF) and mortality after gastrectomy. We aimed to describe the causes of organ failure and mortality related to gastrectomy for gastric cancer and to identify patients with POF who are at a risk of failure to rescue (FTR). METHODS: The study examined patients with POF or in-hospital mortality in Seoul National University Hospital between 2005 and 2014. We identified patients at a high risk of FTR by analyzing laboratory findings, complication data, intensive care unit records, and risk scoring including Acute Physiology and Chronic Health Evaluation (APACHE) IV, Sequential Organ Failure Assessment (SOFA) score, and Simplified Acute Physiology Score (SAPS) 3 at ICU admission. RESULTS: Among the 7304 patients who underwent gastrectomy, 80 (1.1%) were identified with Clavien-Dindo classification (CDC) grade ≥ IVa. The numbers of patients with CDC grade IVa, IVb, and V were 48 (0.66%), 11 (0.15%), and 21 (0.29%), respectively. Pulmonary failure (43.8%), surgical site complication (27.5%), and cardiac failure (13.8%) were the most common causes of POF and mortality. Cancer progression (100%) and cardiac events (45.5%) showed high FTR rates. In univariate analysis, acidosis, hypoalbuminemia, SOFA, APACHE IV, and SAPS 3 were identified as risk factors for FTR (P < 0.05). Finally, SAPS 3 was identified as an independent predictive factor for FTR. CONCLUSIONS: Cancer progression and acute cardiac failure were the most lethal causes of FTR. SAPS 3 is an independent predictor of FTR among POF patients after gastrectomy.
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Fracaso de Rescate en Atención a la Salud , Gastrectomía/efectos adversos , Insuficiencia Cardíaca/etiología , Insuficiencia Respiratoria/etiología , Neoplasias Gástricas/cirugía , APACHE , Acidosis/etiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/mortalidad , Mortalidad Hospitalaria , Humanos , Hipoalbuminemia/etiología , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Periodo Posoperatorio , Insuficiencia Respiratoria/mortalidad , Factores de Riesgo , Puntuación Fisiológica Simplificada AgudaRESUMEN
BACKGROUND: Understanding the natural progression of untreated gastric cancer is critical for determining the disease prognosis as well as treatment options and timing. The aim of this study is to analyze the natural history of gastric cancer. PATIENTS AND METHODS: We included patients with gastric cancer who had not received any treatment and were staged using endoscopy/endoscopic ultrasonography and computed tomography on at least two follow-up visits during intervals of nontreatment. Tumor volumes were also measured in addition to the staging. Survival of each stage at diagnosis was also analyzed. RESULTS: A total of 101 patients were included. The mean follow-up period was 35.1 ± 34.4 months. The gastric cancer doubling time was 11.8 months for T1 and 6.2 months for T4. The progression time from early gastric cancer to advanced gastric cancer was 34 months. It decreased as the stages advanced: from 34 months between tumor-nodes-metastasis stage I and II to 1.8 months between stage III and IV. No variable was identified as a risk factor for cancer progression. The 5-year survival rates of untreated patients were 46.2% in stage I and 0% in stage II, stage III, and stage IV. CONCLUSIONS: The progression and doubling times of gastric cancer shorten as the stages advance. Objective data reported in this study can be a critical factor in determining treatment timing and screening interval.
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Adenocarcinoma Mucinoso/mortalidad , Carcinoma de Células en Anillo de Sello/mortalidad , Neoplasias Gástricas/mortalidad , Adenocarcinoma Mucinoso/diagnóstico por imagen , Adenocarcinoma Mucinoso/secundario , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células en Anillo de Sello/diagnóstico por imagen , Carcinoma de Células en Anillo de Sello/secundario , Progresión de la Enfermedad , Endosonografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Neoplasias Gástricas/diagnóstico por imagen , Neoplasias Gástricas/patología , Tasa de SupervivenciaRESUMEN
BACKGROUND: The comprehensive complication index (CCI) integrates all complications of the Clavien-Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC. METHODS: Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution. RESULTS: From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p < 0.05). The CCI demonstrated a stronger relationship with hospital stay (ρ = 0.721, p < 0.001) than did the CDC (ρ = 0.634, p < 0.001). For prolonged hospital stays (≥30 days), only the CCI showed a moderate correlation (ρ = 0.544, p = 0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time-event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed. CONCLUSIONS: The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.
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Gastrectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Índice de Severidad de la Enfermedad , Neoplasias Gástricas/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
BACKGROUND: To examine the effect and mechanism of Roux-en-Y gastric bypass (RYGB) on the improvement of diabetes according to the length of anastomosis and the gastric pouch volume in an animal model. METHODS: Glucose intolerance was induced with a high-fat diet for 3 months in Sprague-Dawley rats. The animals were subjected to conventional RYGB (cRYGB; 5% gastric pouch with 15-cm Roux limb, 40-cm biliopancreatic limb; n = 9), short-limb RYGB (sRYGB; 5%, 8, 4 cm; n = 9), fundus-sparing RYGB (fRYGB; 30%, 8, 4 cm; n = 9), or sham operation (n = 9). After 6 weeks, oral glucose tolerance tests (OGTTs) were performed, and gut hormones including insulin, total GLP-1, GIP, and ghrelin were analyzed. RESULTS: The cRYGB group showed significantly decreased food intake, body weight, and random glucose (p < 0.05). sRYGB resulted in a similar change of body weight loss to that of cRYGB, but with no improvement of hyperglycemia. The fRYGB group showed similar changes of body weight and random glucose to those of the sham group. In cRYGB and sRYGB, the level of insulin steeply increased until 30 min during OGTT. GLP-1 was higher at 30 min in cRYGB than in other groups, without significance. The fRYGB group showed a slowly increasing pattern in OGTT and GLP-1, and the lowest peak point in insulin and GIP. CONCLUSION: cRYGB with 95% gastric resection was needed to achieve not only weight loss but also diabetes improvement, which could be related to the increase in GLP-1.
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Diabetes Mellitus Tipo 2/cirugía , Gastrectomía/métodos , Derivación Gástrica/métodos , Neoplasias Gástricas/cirugía , Animales , Diabetes Mellitus Tipo 2/complicaciones , Masculino , Ratas , Ratas Sprague-Dawley , Neoplasias Gástricas/complicaciones , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: The number of elderly patients undergoing gastric cancer surgery has recently increased. We therefore evaluated the short- and long-term outcomes of elderly patients after curative gastrectomy. METHODS: Overall, 824 patients were included in this retrospective study, which comprised of a non-elderly group (60-64 years; n = 558), an early-elderly group (75-79 years; n = 198), and a late-elderly group (≥80 years; n = 68) who underwent curative gastrectomy for gastric cancer between 2005 and 2009. Postoperative complications, according to the Clavien-Dindo classification, and survival of both elderly groups were compared with the non-elderly group. Postoperative life expectancy of the late-elderly group was compared with the corresponding aged general population. RESULTS: Overall and severe (grade III or higher) complications in the early-elderly group were comparable with the non-elderly group; however, those in the late-elderly group were significantly more common than in the non-elderly group (p = 0.013 and p = 0.043, respectively). Multivariable analysis revealed that age ≥80 years was an independent risk factor for severe complications (hazard ratio 3.02, 95 % confidence interval 1.12-8.17; p = 0.029), and the disease-specific survivals of both elderly groups were comparable with the non-elderly group in all TNM stages. Postoperative life expectancy of late-elderly patients eliminating death from recurrence was comparable with the corresponding aged general population eliminating death from gastric cancer. CONCLUSIONS: Gastric cancer surgery in elderly patients aged ≥80 years achieves reasonable long-term survival despite the increased risk of severe complications.
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Adenocarcinoma/mortalidad , Gastrectomía/mortalidad , Complicaciones Posoperatorias/mortalidad , Neoplasias Gástricas/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugía , Tasa de Supervivencia , Factores de TiempoRESUMEN
OBJECTIVE: The aim of this study was to analyze clinical and laboratory variables associated with complications after gastrectomy for gastric cancer to predict candidates for successful early discharge. METHODS: Consecutive patients undergoing gastrectomy at Seoul National University Hospital from January through December 2013 were identified from a prospective complications database. Clinicopathologic and postoperative laboratory parameters were analyzed to determine variables associated with complications. An additional validation study was performed from March through May 2014. RESULTS: Overall, complications occurred in 180/855 patients (21.1 %). Age >68 years (odds ratio [OR] 1.64), use of an open approach (OR 1.9), and use of combined resection (OR 1.67) were significant independent risk factors for complications (p < 0.05). The postoperative day (POD) 5 to preoperative white blood cell count (WBC) ratio (risk ratio [RR] 2.01), C-reactive protein (CRP) level on POD 5 (RR 1.1), and maximum body temperature on POD 4 (RR 2.36) independently predicted complications in a multivariate analysis (p < 0.05). After establishing an early discharge profile (EDP) based on these six variables, 152/855 patients (17.8 %) were predicted to have an uncomplicated course. Of these, 8/152 (5.3 %) experienced complications. In a validation study of 217 patients, 43/217 (19.8 %) were candidates for early discharge on POD 5, and 3 (7.0 %) had a false-positive EDP. CONCLUSIONS: Patients younger than 68 years of age who underwent laparoscopic gastrectomy without combined resection might be candidates for early discharge on POD 5 if the POD 5 to preoperative WBC ratio is ≤1.2, POD 5 CRP level is ≤5.38 g/mL, and POD 4 body temperature is ≤37.4 °C.
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Gastrectomía , Alta del Paciente , Complicaciones Posoperatorias/epidemiología , Neoplasias Gástricas/cirugía , Factores de Edad , Anciano , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , República de Corea/epidemiología , Factores de Riesgo , Neoplasias Gástricas/patología , Resultado del TratamientoRESUMEN
Purpose: The introduction of insurance coverage in Korea has led to a rise in the number of bariatric and metabolic surgeries. This study aims to provide a comprehensive report on the nationwide status of these surgeries from 2019 to 2022, utilizing data from the Korean Society of Metabolic and Bariatric Surgery (KSMBS) database registry. Materials and Methods: This study analyzed data from the KSMBS registry, collected from 68 certified surgeons across 58 institutions from January 2019 to December 2022. After excluding non-relevant cases, the final analysis included 7,377 patients. Results: Annually, data for 1,869, 1,934, 1,782, and 1,792 patients were collected from 2019 to 2022, respectively. The rate of revisional operations accounted for 7.1%, 8.2%, 4.6%, and 4.5% of the total cases each year. The most common primary surgery was Sleeve Gastrectomy (SG, ranging from 71.1% to 78.9%), followed by Roux-en-Y Gastric Bypass (RYGB, ranging from 9.6% to 13.4%). The surgeries demonstrated a high safety profile, with a low morbidity rate (0.5% to 0.9%) and a zero mortality rate over the 4 years. Within 2 years post-operation, the Total Weight Loss Percentage was similar among patients who underwent SG, RYGB, and Sleeve Plus procedures. Conclusion: The number of bariatric and metabolic surgeries in Korea has increased significantly since the introduction of national insurance coverage. SG was the most performed primary procedure. All surgical procedures showed safe short-term outcomes and yielded reasonable results upon follow-up, indicating a positive impact of insurance coverage on the accessibility and safety of surgeries.
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Metabolic surgery (MS) is a surgery that focuses on improving obesity-related comorbidities. It is often referred to as "diabetic surgery" because of its focus on treating type 2 diabetes. MS is distinguished from bariatric surgery (BS), in which weight loss is the primary goal. However, from a broader perspective, all surgeries for obese patients with diabetes can be considered MS. In Korea, metabolic and bariatric surgery (MBS) has been covered by the national health insurance since 2019. Patients with a body mass index (BMI) ≥35 or those with a BMI ≥30 and obesity-related comorbidities were eligible for MBS. Simultaneously, MS for patients with BMI values between 27.5 and 30 was partly reimbursed. The two major metabolic surgeries are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). According to the registry of the Korean Society of Metabolic and Bariatric Surgery, 1,560 metabolic surgeries for obese patients with diabetes were performed between 2019 and 2021 in Korea, which was approximately 35.6% of all bariatric surgeries. SG was the most common, followed by RYGB and duodenal switch surgery. When dividing the patients with diabetes who underwent MBS into two groups, specifically those with BMI <35 and ≥35, we found that SG was performed most common procedure in both groups. However, there was a higher proportion of RYGB and duodenal switch operation in the former, indicating a difference in surgical methods between the two groups. MS is a promising tool for the management of poorly controlled diabetes. More data are needed to establish proper patient selection and choice of surgical type.
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BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG. METHODS: A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms. RESULTS: The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%). CONCLUSION: In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.
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Reflujo Gastroesofágico , Laparoscopía , Obesidad Mórbida , Humanos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Estudios Retrospectivos , Laparoscopía/efectos adversos , Gastrectomía/efectos adversos , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/etiología , Obesidad/complicaciones , República de Corea/epidemiología , Resultado del TratamientoRESUMEN
PURPOSE: Resectional Roux-en-Y gastric bypass (RRYGB) is considered an alternative bariatric surgery in countries with a high incidence of stomach cancer because there is no excluded stomach after RRYGB. This study aimed to evaluate the efficacy and safety of RRYGB. MATERIALS AND METHODS: This study included patients who underwent RRYGB and sleeve gastrectomy (SG) between 2011 and 2021. Surgical complications and metabolic and nutritional profiles were compared between the patients preoperatively and at 1, 6, and 12 months after surgery. RESULTS: Twenty and seventy-six patients underwent RRYGB and SG, respectively; 7 in the SG group were lost to follow-up within 1 year. Surgical complications and baseline characteristics were comparable between two groups, except for diabetes (90.0% vs. 44.7%, p < 0.001). The decrease of HbA1c levels and incidence of reflux esophagitis were lower in the RRYGB group compared to that of SG at 1-year postoperative (-3.0% vs. -1.8%, p = 0.014; 0% vs. 26.7%, p = 0.027). The percentage of total weight loss at 1- year postoperative and incidence of dumping syndrome were comparable between the two groups. The RRYGB group had significantly lower total cholesterol level (161.9 mg/dl vs. 196.4 mg/dl, p < 0.001), but higher incidence of vitamin B12 deficiency (30.0% vs. 3.6%, p = 0.003) at 1 year postoperative compared to those of the SG group. CONCLUSIONS: The RRYGB group had better postoperative outcomes for diabetes and dyslipidemia without increasing surgical complications compared to that of the SG group. Thus, RRYGB can be considered a safe and effective alternative in areas where gastric cancer is prevalent.
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Derivación Gástrica , Obesidad Mórbida , Humanos , Obesidad Mórbida/cirugía , Derivación Gástrica/efectos adversos , Reoperación , Síndrome de Vaciamiento Rápido/epidemiología , Síndrome de Vaciamiento Rápido/etiología , Gastrectomía/efectos adversos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Investigation of responsiveness-associated genes using longitudinal mutation analyses after standard treatments in recurrent gastric cancer (GC) is limited. OBJECTIVE: To evaluate the somatic mutations associated with resistance to combined treatment involving fluorouracil (FU) or platinum (PL) in advanced GC. METHODS: Samples from patients with advanced GC treated with FU or PL alone, or surgery plus FU/PL, were studied. GC patients who relapsed after standard chemotherapy (FU/PL) and with presence of tumor samples from initial diagnosis and recurrence were included. Targeted sequencing analysis of 143 cancer-related genes was performed using an Oncomine Comprehensive Cancer Panel. RESULTS: Matched samples of primary and recurrent lesions were analyzed in sixteen patients with GC. When genes with recurrent mutations in two or more patients were used as specific findings, a total of 26 genes were found. TP53 was the most predominantly increased allele frequency (AF) in recurrent GCs after standard treatment. The mutational AF of ERBB2, PTEN, and BRCA2 also commonly increased, suggesting the role of these mutations in treatment resistance, whereas the mutational AF of VLH, NF1, and STK11 frequently decreased in recurrent tumors, suggesting the role of these mutations in increasing sensitivity to treatment. TCGA gastric cancer data (n = 436) were analyzed, and mutation sites detected in 16 GC patients in this study were in agreement with TCGA cohort with some exceptions. Overall survival according to gene expression associated with chemotherapy responsiveness exhibited compatible patterns with gain or loss-of-function mutations of each gene. CONCLUSIONS: Mutations in TP53, ERBB2, PTEN, BRCA2, VHL, NF1, and STK11 are candidate somatic alterations related to chemoresistance in GC.
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Neoplasias Gástricas , Fluorouracilo/uso terapéutico , Genes Relacionados con las Neoplasias , Humanos , Mutación , Platino (Metal) , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/genética , Neoplasias Gástricas/patologíaRESUMEN
The enhanced recovery after surgery (ERAS) program is now widely applied in bariatric surgeries and other surgical procedures. The ERAS program in bariatric surgery consists of various components similar to that in colorectal surgery or other procedures. The major concept of the ERAS protocol relies on a multidisciplinary and multimodal approach to resolve various problems after surgical treatment. The key principles of the ERAS program in bariatric surgery include patient education, opioid-sparing multimodal pain management, prophylaxis of postoperative nausea and vomiting, goal-directed fluid therapy, and minimizing insulin resistance and catabolism. Several guidelines and studies, including randomized clinical trials and systematic reviews, have advocated for the ERAS program in bariatric surgery, which has consistently shown advantages in shortening hospital stay without increasing morbidity. The systematic application of the ERAS program in bariatric patients results in less pain and early recovery and should be routinely recommended.
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BACKGROUND: Tumor localization during totally laparoscopic gastrectomy is challenging owing to the invisibility of tumors on the serosal surface. We aimed to evaluate the clinical significance of intra-operative gastroscopy in totally laparoscopic partial gastrectomy. METHODS: We reviewed 1084 gastric cancer patients who underwent either intra- or extracorporeal partial gastrectomy between 2014 and 2018. The intracorporeal group with intra-operative gastroscopy (intra-operative gastroscopy group, n = 187), the intracorporeal group without intra-operative gastroscopy (non-intra-operative gastroscopy group, n = 267), and the extracorporeal group (n = 630) were evaluated for the adequacy of surgical resection margins. We assessed whether total gastrectomy could be avoided according to the performance of intra-operative gastroscopy if the tumor was located within 3-5 cm away from the gastroesophageal junction. RESULTS: The proximal margin positivity was lesser in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (0% versus 2.2%; P = 0.045) but similar to that in the extracorporeal group (0% versus 0.6%; P = 0.579). The number of cases with proximal resection margins < 1 cm was lower in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (3.7% versus 9.4%; P = 0.025) but comparable with that in the extracorporeal group (3.7% versus 4.1%; P = 0.815). Among 94 patients with lesions located within 3-5 cm apart from the gastroesophageal junction, the intra-operative gastroscopy group (n = 47) had fewer patients who underwent total gastrectomy than the non-intra-operative gastroscopy group (n = 47) (12.8% versus 44.7%; P = 0.001). Intra-operative gastroscopy was the only independent factor that prevented total gastrectomy (P = 0.001). CONCLUSION: Intra-operative gastroscopy can provide margin safety during intracorporeal partial gastrectomy, avoiding unnecessary total gastrectomy.
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Laparoscopía , Neoplasias Gástricas , Gastrectomía , Gastroscopía , Humanos , Márgenes de Escisión , Estudios Retrospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/cirugíaRESUMEN
BACKGROUND/OBJECTIVE: The number of gastric cancer and type II diabetes mellitus is increasing in Korea. Metabolic surgery could be extended to gastric cancer patients with type II diabetes, especially those who are expected to achieve long-term survival. This study aimed to investigate change of diabetic status in patients undergoing long-limb Roux-en-Y bypass reconstruction compared with conventional Billroth II after curative gastrectomy. In total, 130 patients from five university hospital centers underwent long-limb Roux-en Y reconstruction after radical distal gastrectomy. METHODS: In the long-limb group, the length of biliopancreatic limbs was more than 80 cm, and the length of the Roux limb was more than 80 cm. The control group comprised 96 patients who underwent conventional Billroth II reconstruction after distal gastrectomy. Follow-up data at three, six, nine, and 12 months were compared between the two groups. RESULTS: Fasting blood sugar (FBS) and hemoglobin (Hb) A1c levels decreased more significantly in the long-limb Roux-en-Y group (FBS: 28.8 mg/dL; HbA1c: 0.72%). However, decreases in body mass index, albumin, and hemoglobin did not differ significantly between the two groups. Diabetes control significantly improved in the long-limb group. In multivariate analysis, long-limb bypass reconstruction was the significant factor for glycemic outcomes. CONCLUSION: Roux-en-Y bypass with increased length of limbs after gastrectomy shows a favorable glycemic control for gastric cancer patients with type II diabetes without nutritional deficit and anemia. To obtain future perspectives, large-scale prospective studies with long-term outcomes are needed.
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Anastomosis en-Y de Roux/métodos , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/cirugía , Gastrectomía , Páncreas/cirugía , Neoplasias Gástricas/complicaciones , Neoplasias Gástricas/cirugía , Anciano , Biomarcadores/sangre , Glucemia , Diabetes Mellitus Tipo 2/diagnóstico , Ayuno , Femenino , Estudios de Seguimiento , Derivación Gástrica/métodos , Gastroenterostomía , Hemoglobina Glucada , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Páncreas/patología , República de Corea , Resultado del TratamientoRESUMEN
BACKGROUND: Near-infrared (NIR) imaging with indocyanine green (ICG)-enhanced fluorescence is widely used in laparoscopic surgery. This study aimed to evaluate this technique's feasibility and usefulness in intraoperatively assessing vascular perfusion in a laparoscopically harvested omental flap. MATERIALS AND SURGICAL TECHNIQUES: From March 2015 to February 2016, we prospectively evaluated patients undergoing breast cancer surgery followed by immediate breast reconstruction using a laparoscopically harvested omental flap. After laparoscopic preparation of the pedicled graft, the perfusion area of the omental graft was evaluated by using intraoperative Doppler ultrasonography and NIR imaging with intravenous ICG injection. Graft viability was evaluated by using Doppler ultrasonography 2 days postoperatively; for cosmetic outcome, Breast Cancer Conservative Treatment Cosmetic Results software was used 1 month postoperatively. DISCUSSION: The laparoscopic harvesting of an omental flap was successfully performed in eight patients without conversion to open surgery. The mean time to the initial detection of ICG-enhanced fluorescence uptake was 3.25 ± 1.16 minutes. On intraoperative Doppler ultrasonography, a pulseless area ≥10% was detected in five patients (62.5%). However, NIR imaging revealed no patients had an ischemic portion ≥10%. There were no ICG-related intraoperative or postoperative complications. All patients showed patent vessels on Doppler ultrasonography 2 days postoperatively. Cosmetic outcomes were mostly favorable 1 month postoperatively. The Breast Cancer Conservative Treatment Cosmetic Results evaluation 1 month postoperatively showed excellent, good, and fair results, with no poor scores. With regard to vascular perfusion, ICG-enhanced NIR imaging is a feasible and useful tool for harvesting a laparoscopic omental flap in breast cancer patients.
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Neoplasias de la Mama/cirugía , Laparoscopía/métodos , Mamoplastia/métodos , Cirugía Asistida por Computador/métodos , Colgajos Quirúrgicos , Adulto , Colorantes , Femenino , Fluoroscopía , Humanos , Verde de Indocianina , Persona de Mediana EdadRESUMEN
INTRODUCTION: Microbial ecology is reported to be an important regulator of energy homeostasis and glucose metabolism. Microbes secrete extracellular vesicles (EVs) during their proliferation and death to communicate with other cells. To investigate the roles of gut microbiota in glucose metabolism, we analyzed serial changes of gut microbe and microbial EV composition before and after bariatric/metabolic surgery (BMS). METHODS: Twenty-eight Wistar rats were fed on high-fat diet (HFD) to induce obesity and diabetes. Five of them compared with 5 rats fed on regular chow diet (RCD). Among the remaining 23 rats, Roux-en-Y gastric bypass (RYGB) (n = 10), sleeve gastrectomy (SG) (n = 10), or sham operation (n = 3) was randomly performed. Gut microbiota and EVs from fecal samples were analyzed by 16S rDNA amplicon sequencing. RESULTS: The present study showed that microbial diversity was decreased in HFD-fed rats versus RCD-fed rats. In addition, BMS reversed glucose intolerance and microbial richness which were induced by HFD. In terms of microbiota and microbial EV composition, both RYGB and SG enhance the composition of phyla Proteobacteria, Verrucomicrobia, and their secreting EVs, but decrease phylum Firmicutes and its EVs. We tried to demonstrate specific genera showed a significant compositional difference in obesity/diabetes-induced rats compared with normal rats and then restored similarly toward normal rats' level after BMS. At the genus level, Lactococcus, Ruminococcus, Dorea in Firmicutes(p), Psychrobacter in Proteobacteria(p), and Akkermansia in Verrucomicrobia(p) fit these conditions after BMS. CONCLUSION: We suggest that these genera are the candidates contributing to obesity and diabetes improvement mechanism after BMS.
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Cirugía Bariátrica/métodos , Diabetes Mellitus Experimental/cirugía , Vesículas Extracelulares/metabolismo , Microbioma Gastrointestinal , Obesidad/cirugía , Animales , Bacterias/clasificación , Bacterias/aislamiento & purificación , Técnicas de Tipificación Bacteriana , Diabetes Mellitus Experimental/metabolismo , Diabetes Mellitus Experimental/microbiología , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/microbiología , Diabetes Mellitus Tipo 2/cirugía , Dieta Alta en Grasa , Heces/microbiología , Gastrectomía , Derivación Gástrica , Masculino , Metagenómica/métodos , Obesidad/metabolismo , Obesidad/microbiología , Periodo Posoperatorio , Ratas , Ratas WistarRESUMEN
BACKGROUND: Anastomotic leakage is a severe complication after gastric cancer surgery. Inadequate blood supply is regarded as an important risk factor. The aim of the study was to evaluate the feasibility and usefulness of intraoperative assessment of anastomotic vascular perfusion in gastric cancer surgery using near-infrared (NIR) camera imaging with indocyanine green (ICG)-enhanced fluorescence technique. MATERIALS AND METHODS: From March 2015 to 2016, 30 patients undergoing laparoscopic gastrectomy for gastric cancer were prospectively evaluated. After completing the anastomosis, 2.5-5.0 mg of ICG was injected via peripheral veins. All anastomoses and resection margins were investigated using NIR camera to assess anastomotic perfusion. The assessment was performed using the adopted perfusion score of fluorescence activity, which ranged from 1 to 5 (1 = no uptake, and 5 = iso-fluorescent to all other segments). RESULTS: Twenty-six distal gastrectomy (20 gastroduodenostomies, 6 gastrojejunostomies), 3 total gastrectomies (TG), and 1 pylorus-preserving gastrectomy were performed. The gap of visualization was 4.1 ± 3.2 minutes (range, 2-15) after ICG injection. Twenty-three of 30 patients (76.7%) showed technically successful ICG visualization. Among gastroduodenostomies, the average scores for gastric and duodenal sides were 3.5 and 3.7. Among gastrojejunostomies, the average scores for gastric, jejunal, and duodenal stump sides were 3.5, 4.0, and 3.8 (jejunojejunostomy, 3.5). Among TG, the average scores for esophagojejunostomy, duodenal stump, and jejunojejunostomy were 3.7, 4.0, 4.0, and 4.7. One case of leakage occurred in this study. Other complications included fluid collection and stenosis in 1 patient each. CONCLUSIONS: This study showed intraoperative ICG angiography using NIR camera is feasible and provides imaging of anastomotic blood flow. Further studies are needed for practice.
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Gastrectomía/métodos , Verde de Indocianina/farmacología , Intestinos/irrigación sanguínea , Laparoscopía/métodos , Arterias Mesentéricas/fisiopatología , Imagen Óptica/métodos , Imagen de Perfusión/métodos , Anastomosis Quirúrgica/métodos , Fuga Anastomótica/prevención & control , Colorantes/farmacología , Femenino , Fluorescencia , Humanos , Masculino , Arterias Mesentéricas/diagnóstico por imagen , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Estudios Prospectivos , Factores de Riesgo , Circulación Esplácnica/fisiologíaRESUMEN
The aim of the current study is to determine the predictive value of alpha-synuclein (AS) aggregation in stomach surgical specimens in combination with selected clinical prodromal markers (CPMs) for development of Parkinson disease (PD) in a normal population. We organized a prospective, long-term, clinicopathologic cohort of patients without neurological diseases who received a radical operation for early gastric cancer (EGC) between ages 50 and 65â¯years. The participants will be followed for up to 10â¯years and screened for CPMs and motor symptoms by annual telephone interview. If a participant reports one or more positive answers to screening questions about motor symptoms, they will be regarded as having possible parkinsonism. A movement disorder specialist will then evaluate whether that participant has PD. The primary outcome is the development of PD during the 10-year follow-up. The recruitment period has been completed, and the baseline clinical characteristics are compared between participants with and without possible parkinsonism. A total of 718 participants (mean age: 60.1⯱â¯5.9) was recruited. The motor symptom screening questionnaire revealed 65 patients with possible parkinsonism (9.0%) at baseline. Patients with possible parkinsonism answered that they had subjective loss of smell more than those without parkinsonism at the time of recruitment (18.5% vs 8.3%) and operation (15.4% vs 6.3%). However, the objective odor discrimination test showed no difference between patients with and without possible parkinsonism. Baseline assessments revealed a sufficient number of patients with possible parkinsonism, which will be confirmed as PD or not in subsequent follow-up visits.
Asunto(s)
Detección Precoz del Cáncer/métodos , Enfermedad de Parkinson/diagnóstico , Enfermedad de Parkinson/epidemiología , Síntomas Prodrómicos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiología , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/fisiopatología , Estudios Prospectivos , Neoplasias Gástricas/fisiopatologíaRESUMEN
PURPOSE: This study assessed the feasibility of near-infrared (NIR) imaging with indocyanine green (ICG) in investigating the completeness of laparoscopic lymph node (LN) dissection for gastric cancer. MATERIALS AND METHODS: Patients scheduled for laparoscopic gastrectomy for treating gastric cancer were enrolled in the study. After intraoperative submucosal ICG injection (0.05 mg/mL), LN dissection was performed under conventional laparoscopic light. After dissection, the LN stations of interest were examined under the NIR mode to locate any extra ICG-stained (E) tissues, which were excised and sent for pathologic confirmation. This technique was tested in 2 steps: infra-pyloric LN dissection (step 1) and review of all stations after proper radical node dissection (step 2). RESULTS: In step 1, 15 patients who underwent laparoscopic pylorus-preserving gastrectomy (LPPG) and 15 patients who underwent laparoscopic distal gastrectomy (LDG) were examined. Seven and 2 E-tissues were obtained during LPPG and LDG, respectively. From the retrieved E-tissues, 1 and 0 tissue obtained during LPPG and LDG, respectively, was confirmed as LN. In step 2, 20 patients were enrolled (13 D1+ dissection and 7 D2 dissection). Six E-tissues were retrieved from 5 patients, and 1 tissue was confirmed as LN in the pathologic review. Overall, 15 E-tissues were detected and removed, and 2 tissues were confirmed as LNs in the pathologic review. Both nodes were from LN station #6, with 1 case each in the LDG and LPPG groups. CONCLUSIONS: NIR imaging may provide additional node detection during laparoscopic LN dissection for gastric cancer, especially in the infra-pyloric area.
RESUMEN
BACKGROUND: We sought to determine the optimal timing of IH repair in preterms and the need for routine contralateral exploration. METHODS: Medical records of 3690 pediatric patients who underwent unilateral IH repair between January 1998 and December 2009 were reviewed. We assessed medical record review and telephone interviews. In total, 1990 patients were enrolled in the study. Early, early-delayed, and late repair were defined as herniorrhaphy performed within 7 days of diagnosis, later than 7 days of diagnosis, and after discharge from the NICU, respectively. RESULTS: Of 1990 patients, 90 preterms and 1900 full-terms were included. Among these, 7, 11 and 72 preterm patients received early, early-delayed and late IH repairs, respectively. Preoperative incarceration and postoperative complication rates were not different, but the recurrence rate was higher in the early repair group. Two group analysis of early and early-delayed vs. late repairs indicated similar results. The rates of synchronous and metachronous bilateral IH (SBIH, MBIH) were observed to be higher and the diagnostic interval of MBIH was shorter in preterms than in full-terms (35.6% vs. 15.9%, P < 0.001; 12.2% vs. 6.3%, P < 0.001; 5.2 vs. 41.8 months, P = 0.003). CONCLUSION: Our results indicate that IH repair is safe to perform in preterm babies in the NICU at a delayed or late stage since the preoperative incarceration and recurrence rates were not different. Contralateral exploration could be considered in preterms because the rates of SBIH and MBIH were significantly higher and the MBIH diagnosis interval was shorter than in full-terms. LEVEL OF EVIDENCE: III, treatment study.