Comparison of robotic versus laparoscopic total gastrectomy for gastric cancer: A single-center retrospective cohort study in a Japanese high-volume center.

BACKGROUND: Robotic-assisted surgery has become increasingly popular worldwide in recent years. This study aimed to compare the surgical outcomes of robotic total gastrectomy (RTG) and laparoscopic total gastrectomy (LTG) to figure out the advantages of RTG. METHODS: The eligible cases in this study were patients who underwent RTG or LTG for gastric adenocarcinoma at our hospital from January 2014 to December 2022. Propensity score matching (PSM) was employed to balance the underlying selection bias. Then, surgical outcomes of patients were analyzed to be compared. RESULTS: Overall, 255 patients (LTG: 178, RTG: 77) were included in this study. After PSM, 73 patients in each arm were assigned for analysis. Operation time was longer in the RTG than in the LTG (373 vs 336 min, p < 0.01). However, the RTG was associated with shorter postoperative hospital stays (8 vs 9 days, p = 0.04) and lower incidence of grade 3 or higher postoperative complications (1 % vs 11 %, p = 0.03). More lymph nodes were harvested in the RTG (59 vs 47, p < 0.01). CONCLUSIONS: Although RTG requires longer operation time, it has the potential to provide advantages to the patient such as quicker recovery, reduction in postoperative complication, or more yield number of lymph nodes. Regarding survival outcomes, further analysis with enough follow-up is needed.

Changes in pancreatic steatosis by computed tomography 24 months after sleeve gastrectomy in youth with severe obesity.

BACKGROUND: Pancreatic steatosis has been associated with obesity and the metabolic syndrome. Studies in adults have demonstrated improvement in pancreatic steatosis following sleeve gastrectomy (SG) with concomitant improvement in glucose homeostasis. OBJECTIVES: To examine changes in pancreatic steatosis in youth with severe obesity 24 months following SG. SETTING: Academic hospital system. METHODS: Forty-seven youth (13-24 years) with severe obesity (37 females) were followed for 24 months; 23 had SG and 24 were nonsurgical (NS) controls. Attenuations of the pancreas and spleen were measured using computed tomography (CT) at baseline, 12- and 24-month follow-up. Subjects underwent magnetic resonance imaging (MRI) for subcutaneous and visceral adipose tissue (SAT, VAT), dual energy x-ray absorptiometry (DXA) for body composition, blood sampling for glycated hemoglobin (A1C), and fasting and postprandial insulin and glucose. Linear mixed effects (LMEs) models were used to compare within- and between-group changes over 24 months. RESULTS: At baseline, SG had higher body mass index (BMI) versus NS (P = .033). Over 24 months, significant reductions were noted in weight, BMI, VAT, SAT, fat mass (FM), and lean mass (LM) in the SG versus NS groups (P ≤ .0001). There was a significant 24-month decrease in pancreatic steatosis in the SG group (P = .006). In the whole group, 24-month reductions in pancreatic steatosis correlated with BMI and FM decreases. No associations were found between pancreatic steatosis and glucose homeostasis parameters. CONCLUSIONS: Pancreatic steatosis measured by CT improved after SG in youth. Further studies are needed to understand the relationship between pancreatic steatosis and glucose homeostasis.

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

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

A review of brain structural and functional changes using MRI technology in patients who received bariatric surgery.

According to the World Health Organization, obesity is one of the most significant health issues currently because it increases risk for type 2 diabetes and cancer, heart disease, bone health, reproduction, and quality of living and it impacts approximately 500 million adults worldwide. This review analyzed the existing literature focusing on the effects of Metabolic and bariatric surgeries (MBS), including Roux-en-Y gastric bypass and sleeve gastrectomy on changes in brain function and anatomy using magnetic resonance imaging (MRI) technology. A PubMed search using the key words bariatric surgery and MRI conducted in December 2023 resulted in 544 articles. Our literature review identified 24 studies addressing neuroanatomic, neurophysiological, cognitive, and behavioral changes that occurred at different time intervals after different types of bariatric surgery. Our review of the literature found several reports indicating that MBS reverse neuroanatomic alterations and changes in functional connectivity associated with obesity. There were also reported improvements in cognitive performance, memory, executive function, attention, as well as decreased gustatory brain responses to food cues and resting state measures following bariatric surgery. There were instances of improved neural functioning associated with weight loss, suggesting that some neuroanatomic changes can be reversed following weight loss induced by bariatric surgery. Additionally, there were data suggesting that brain connectivity and metabolic health are improved following a bariatric surgical intervention. Together, the existing literature indicates an overall improvement in brain connectivity and health outcomes following bariatric surgery.

Sleeve gastrectomy ameliorates renal injury in obesity-combined hyperuricemic nephropathy mice by modulating the AMPK/Nrf2/ABCG2 pathway.

Hyperuricemic nephropathy (HN) is renal injury caused by hyperuricemia (HUA). While sleeve gastrectomy (SG) has shown promise in improving renal injury in patients with obesity-related HN, the mechanisms are not fully understood. This study induced an obesity-combined HN model in male ob/ob mice and measured serum uric acid (SUA), creatinine, and other biochemical indicators 6 weeks post-surgery. Renal histological changes were evaluated through staining techniques, and the study also assessed renal adenosine monophosphate-activated protein kinase (AMPK) and nuclear factor erythroid 2-related factor 2 (Nrf2) phosphorylation levels and urate transporter ABCG2 expression. In vitro experiments involved Nrf2 knockdown in AMPK-activated HK-2 cells and ChIP to confirm Nrf2 binding to the ABCG2 promoter. Results showed that SG reduced SUA levels, serum creatinine, and blood urea nitrogen, increased p-AMPK, p-Nrf2 protein, and ABCG2 expression, and alleviated renal fibrosis and inflammation. In vitro, Nrf2 knockdown down-regulated ABCG2 expression, and ChIP confirmed Nrf2's role in ABCG2 transcription. The study suggests that SG may improve renal injury in HN mice by modulating the AMPK/Nrf2 pathway and upregulating ABCG2 transcription.

Significance of resected stomach measurements in postoperative delayed gastric emptying following laparoscopic pylorus-preserving gastrectomy.

PURPOSE: We investigated the relationship between the resected stomach measurements, the incidence of delayed gastric emptying (DGE), and food residue 1 year after surgery in patients who underwent laparoscopic pylorus-preserving gastrectomy (PPG). MATERIALS AND METHODS: The DGE group included 10 patients fasting due to nausea, vomiting, abdominal distension, or remnant stomach distension on radiographs; the control group included 36 patients without these symptoms. We compared the size and length of lesser and greater curvatures of the resected stomach and endoscopic findings after 1 year. RESULTS: No significant differences were observed between groups in terms of sex, body mass index, gross type, histology, tumor progression, number of dissected lymph nodes, operating time, or blood loss. The DGE group was older, had a longer postoperative stay, and showed a smaller size and shorter greater curvature of the resected stomach than the control group (p < 0.01 for all). No difference was observed in the length of the lesser curvature of the resected stomach. In addition, there were no disparities in residual food, degree and extent of gastritis, or bile reflux 1 year after gastrectomy. CONCLUSIONS: Measurements of the resected stomach suggest that preventing DGE may be achievable by removing a larger area of the greater curvature and/or stomach during laparoscopic PPG. This implies potential surgical strategy improvements for better outcomes. Further multicenter trials are needed to validate and refine techniques.

The relationship of decision regret with quality of life and comfort level in patients undergoing laparoscopic sleeve gastrectomy: a cross-sectional study.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is one of the effective methods of weight loss. It is essential to determine patients' regret and predictive factors to improve their quality of life and comfort. No study has investigated decision regret and affecting factors in patients undergoing SG in Turkey. OBJECTIVES: The study aimed to determine the relationship of decision regret with quality of life and comfort level in patients undergoing SG. SETTING: The research was carried out with patients who had undergone SG in a private hospital in the west of Turkey. METHODS: The research was conducted as a descriptive, correlational, and cross-sectional study. Data were collected between March and May 2023, and the study was completed with 286 patients. Data were collected using the Personal Information Form, Decision Regret Scale (DRS), Quality of Life Following Obesity Surgery Scale (QoL-OS), and Comfort Scale. RESULTS: Patients' mean score on the DRS was 5.27 ± 13.41 (0-100), the total mean score on the QoL-OS-Biopsychosocial dimension was 79.57 ± 9.35 (18-90), the mean score on the QoL-OS-Complications dimension was 17.17 ± 4.60 (7-35), and the environmental comfort score average was 8.87 ± 2.23 (0-10). Patients' decision regret was significantly affected by the QoL-OS-Biopsychosocial Area dimension in the first place (Beta = -.516; P < .001), social comfort in the second place (Beta = -.278; P < .001), postoperative weight gain in the third place (Beta = .221; P < .001), and complication development in the fourth place (Beta = .163; P < .001). CONCLUSIONS: The study revealed that patients' decision regret levels were very low up to 3 years after surgery and found that low postoperative quality of life and social comfort level, postoperative weight gain, and complications affected decision regret.

Migration and section of esophageal thermometer in laparoscopic sleeve gastrectomy: Clinical case of a preventable complication.

INTRODUCTION AND IMPORTANCE: Laparoscopic sleeve gastrectomy is a prevalent bariatric surgery for managing morbid obesity. Despite its efficacy, complications can arise, particularly from intraoperative devices such as esophageal thermometers and orogastric tubes. These devices, if misplaced or inadequately monitored, can migrate and become entrapped or sectioned during surgery, leading to significant morbidity. CASE PRESENTATION: A 49-year-old female with morbid obesity underwent LSG. During surgery, an esophageal thermometer migrated into the stomach and was inadvertently sectioned during the stapling process. This required additional surgical intervention to remove the severed segments and repair the damage. Postoperative recovery was uneventful after corrective measures were taken. CLINICAL DISCUSSION: This case underscores the critical importance of ensuring the proper placement and continuous monitoring of intraoperative devices, such as esophageal thermometers, to prevent similar preventable complications in future surgical procedures. CONCLUSION: The reviewed cases demonstrate that complications from intraoperative device migration and entrapment during bariatric surgery, while rare, are significant and preventable. Adherence to strict protocols, continuous device monitoring, and enhanced team communication are essential to improve patient safety and surgical outcomes. Implementing these measures can prevent avoidable complications and enhance the efficacy of bariatric surgeries. EVIDENCE BASED MEDICINE RANKING: Level IV.

1- and 2-year outcomes and predictors of weight loss after gastric sleeve to Roux-en-Y gastric bypass conversion: a retrospective cohort study.

BACKGROUND: Sleeve gastrectomy to Roux-en-Y bypass conversion is a commonly performed procedure, yet data are limited on outcomes and their predictors. The purpose of this study is to characterize the long-term outcomes of patients after sleeve-to-bypass conversion and identify predictors of post-conversion outcomes. METHODS: We performed a retrospective cohort study of patients who underwent sleeve-to-bypass conversion for obesity across four hospitals from 06/2017 to 04/2023. Predictors of the below-average percent excess weight loss (%EWL; relative to pre-conversion weight) at 1 and 2 years following conversion were identified using multivariate logistic regression models adjusting for comorbidities, demographics, and neighborhood socioeconomic status. RESULTS: 150 Patients undergoing sleeve-to-bypass conversion were identified. 99 had 1-year data and 63 had 2-year data. Mean %EWL at 1- and 2-years following conversion were 40.2% and 37.4%, respectively. EWL > 40% after sleeve gastrectomy was an independent predictor of the below-average %EWL 1-year post-conversion (OR 10.0, 95% CI 2.2-63.0, p < 0.01), and BMI > 40 kg/m2 at the time of conversion was an independent predictor of both 1- and 2-year below-average %EWL post-conversion (p = 0.01 and 0.05, respectively). Insignificant predictors of the below-average %EWL after conversion included: weight regain after sleeve, time between sleeve and conversion, alimentary limb length, and any bariatric surgery prior to sleeve gastrectomy. CONCLUSION: Patients should be counseled that the typical expected %EWL for sleeve-to-bypass conversion is less than the 50% EWL benchmark of success for index bariatric operations. The main predictors of a suboptimal conversion outcome are > 40% EWL after sleeve or > 40 BMI kg/m2 at the time of conversion. Most variables in our analysis were not predictors of post-conversion %EWL, including weight regain between sleeve and conversion, alimentary limb length, and time interval between procedures, which suggests that these factors should not play a large role when considering sleeve-to-bypass conversion.

Acute Mental Disorder Caused by Vitamin B12 Deficiency Eight Years After Total Gastrectomy.

Vitamin B12 deficiency can cause a variety of diseases. The most common disease is macrocytic anemia, but it has also been found to be a cause of psychiatric disorders. The causes of deficiency are varied, and diagnosis is often difficult. Here, we report a patient who developed mental disorders due to vitamin B12 deficiency after total gastrectomy. A 37-year-old female, eight years after total gastrectomy, was withdrawn at her workplace, talking and acting abnormally. The family had seen unusual behavior for three days. The patient had no particular history of mental illness. The possibility of herpes encephalitis was suspected, and the patient was referred to our hospital, but there were no specific findings in the head on imaging examination. Blood tests showed no macrocytic anemia. Spinal fluid cytology and electroencephalography showed no specific findings, and herpes DNA was negative. Metabolic factors such as vitamin deficiency were considered, and intravenous vitamin replacement therapy was initiated. The psychiatric symptoms improved rapidly after vitamin B12 supplementation was started. On the fifth day of her hospitalization, it was discovered that her vitamin B12 level at the time of admission was extremely low. Typically, vitamin B12 deficiency is associated with macrocytic anemia, but in this patient, serum iron was also decreased, indicating a mixed anemia, making the diagnosis difficult. The patient had undergone a total gastrectomy for gastric cancer eight years ago, and the psychiatric symptoms were thought to be due to impaired vitamin B12 absorption caused by intrinsic factor deficiency. Since then, oral replacement therapy and intramuscular injection have been continued without recurrence of symptoms. Disturbances of consciousness may have many causes, but when there is a history of gastrectomy, we should also consider vitamin B12 deficiency when examining patients.

Predictors of postoperative bleeding after minimally invasive bariatric surgery.

BACKGROUND: Minimally invasive bariatric surgeries provide effective weight loss with fewer complications. However, postoperative bleeding remains a significant concern due to its potential for serious morbidity and mortality. This study aimed to identify factors predicting postoperative bleeding following laparoscopic and robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS: We analyzed patients who underwent SG and RYGB using the MBSAQIP database from 2015 to 2021. Four multivariate logistic regression analyses were conducted to investigate the relationship between postoperative bleeding and 24 independent factors for laparoscopic SG (lapSG), robotic SG (rSG), laparoscopic RYGB (lapRYGB), and robotic RYGB (rRYGB). RESULTS: We analyzed 659,294 lapSG, 53,548 rSG, 267,171 lapRYGB, and 22,492 rRYGB patients. In lapSG, the most significant factors included anticoagulation (OR 3.76; 95% CI 3.13-4.51), renal insufficiency (OR 2.06; 95% CI 1.37-3.09), history of DVT (OR 1.87; 95% CI 1.23-2.85), history of PE (OR 1.69; 95% CI 1.04-2.76, and BMI ≤ 40 (OR 1.22; 95% CI 1.09-1.38). In the rSG group, anticoagulation (OR 4.95; 95% CI 2.83-8.66), COPD (OR 2.80; 95% CI 1.29-6.05), and hyperlipidemia (OR 1.90; 95% CI 1.29-6.05) were significant factors. In lapRYGB, the most significant factors included anticoagulation (OR 3.68; 95% CI 3.11-4.35), renal insufficiency (OR 1.60; 95% CI 1.04-2.44), history of DVT (OR 1.70; 95% CI 1.09-2.07), cardiac stent (OR 1.51; 95% CI 1.09-2.07), and BMI ≤ 40 (OR 1.16; 95% CI 1.03-1.29). For rRYGB, anticoagulation (OR 4.69; 95% CI 2.86-7.70), history of PE (OR 4.28; 95% CI 1.53-12.00), and cardiac stent (OR 2.15; 95% CI 0.06-4.34) were significant. CONCLUSION: Preoperative anticoagulation, renal insufficiency, history of DVT and PE, a cardiac stent, and BMI ≤ 40 are associated with an increased risk of postoperative bleeding. The predictive factors were consistent across laparoscopic and robotic approaches in SG and RYGB procedures.

Intrathoracic Sleeve Migration Following Sleeve Gastrectomy: Incidence and Outcomes.

PURPOSE: With laparoscopic sleeve gastrectomy (LSG) taking its place as the primary metabolic bariatric procedure in the past decade, de novo or persistent gastroesophageal reflux disease (GERD) has come into the spotlight as one of the most debilitating postoperative complications. Among the causes of GERD, intrathoracic migration (ITM) of the sleeve has become an understated yet significant phenomenon. This study aims to analyze the actual incidence of spontaneous ITM at our center, as well as its relationship to the baseline characteristics of patients and perioperative outcomes. MATERIALS AND METHODS: A retrospective chart review of 206 patients who had undergone LSG at our center from July 2019 to December 2022 was done. At 1-year follow-up, a non-enhanced abdominopelvic computed tomography (CT) scan and esophagogastroduodenoscopy (EGD) were performed, and these exams were repeated annually. Baseline characteristics and perioperative outcomes including the clinical disease course of GERD were compared. RESULTS: The incidence of ITM was 14% (n = 29). There was a significant correlation between ITM and postoperative reflux symptoms (p = 0.001). The mean duration of anti-reflux medication use was also significantly longer in the ITM group than in the no ITM group at 17 and 11 months, respectively (p = 0.004). A significantly higher number of patients in the ITM group were diagnosed with esophagitis on postoperative EGD than in the no ITM group (p = 0.002). CONCLUSION: The incidence of ITM using non-enhanced CT was 14%. ITM was significantly correlated to clinical reflux and EGD-confirmed esophagitis.

Anemia rates after one-anastomosis gastric bypass versus sleeve gastrectomy: a retrospective cohort study.

PURPOSE: To compare postoperative anemia rates after one-anastomosis gastric bypass (OAGB) with those after sleeve gastrectomy (SG) in a large nationwide, population-based cohort study. METHODS: We sourced data from the Israeli Bariatric Surgery Registry. The study included a cohort of adults who underwent bariatric surgery (BS) between 2013 and 2017. Hemoglobin (Hb) was measured preoperatively and then 1 and 2 years post-BS. Anemia rates were compared between the patients who underwent OAGB and those who underwent SG, using multivariable analyses. RESULTS: The study comprised 1,052 patients who underwent OAGB and 5,885 patients who underwent SG. Among them, 24.1% and 23.6% were men, respectively, and the preoperative mean body mass index values were 41.7 ± 5.0 and 42.1 ± 5.1 kg/m2, respectively. The 1-year and 2-year postoperative anemia rates were significantly higher after OAGB than after SG, when adjusted for age, pre-surgery BMI, sex and other covariates (1 year: 37.5% vs. 20.2%; adj-OR = 2.43; 95% CI 2.08-2.86; 2 years: 45.1% vs. 28.5%; adj-OR = 1.92; 95% CI 1.59-2.32). CONCLUSIONS: Patients who underwent OAGB had significantly higher anemia rates 1 year and 2 years postoperatively than those who underwent SG. Consequently, vigilant surveillance and intervention strategies post-OAGB should be considered to mitigate the incidence of anemia and its associated complications.

3dct Conduit and Oesophageal Metrics, a Valuable Method to Diagnose Post Sleeve Gastrectomy Abnormalities.

PURPOSE: Reflux after laparoscopic sleeve gastrectomy (LSG) may result from anatomical and functional anomalies in the gastric conduit. Three-dimensional CT scans (3DCT) offer a comprehensive view of gastric anatomy. This study aims to establish specific measurements associated with sleeve abnormalities to standardise the reporting of 3DCT which may help in management of LSG complications. MATERIALS AND METHODS: This retrospective study analysed 64 post-LSG patients who underwent gastric 3DCT. Data included clinical demographics, pre-LSG BMI, BMI at 3DCT, and the duration between surgery and examination. Symptomatology prompts the scan and other concurrent investigations. Various 3DCT measurements were taken, including angularis angle (AA), surface area (ASA), conduit length (CL), proximal maximal surface area (PMSA), and distal maximal surface area (DMSA) of the gastric conduit. Patients were categorised based on endoscopy findings and symptomatology. Outcomes post-revisional surgery were assessed and analysed. RESULTS: 20.3% were male. Pre-LSG BMI and BMI at 3DCT were 45.57 (± 8.3) and 36.3 (± 8.7), respectively. Mean surgery-to-scan period was 6.2 years. 71.8% of patients presented with reflux, regurgitation, or dysphagia, whilst the remainder primarily exhibited weight regain. Patients with endoscopic evidence of stenosis/reflux demonstrated significantly lower gastric volume, ASA, and DMSA (p = 0.002 and p = 0.007, respectively). Oesophageal diameter above the conduit and an ASA to DMSA ratio ≤ 0.5 were negatively associated with AA (p = 0.008 and p = 0.08, respectively). Patients with improved outcomes after revisional bypass and gastrogastrostomy displayed a negative correlation with ASA and positive correlation with the ASA to PMSA ratio (≤ 0.5). CONCLUSION: 3DCT measurements have a potential role in defining post-LSG stenosis and predicting outcomes of revisional surgery. Patients with anatomic abnormalities that are shown on CT appear to improve with anatomic correction.

The effect of preadmission education given to bariatric surgery patients on postoperative recovery: A randomized controlled study.

AIM: To investigate the effect of preadmission education given to laparoscopic sleeve gastrectomy patients on preoperative and postoperative anxiety, postoperative pain, and patient vital signs. METHODS: The study was designed as randomized, controlled, experimental, and single-blind. This study was conducted with 68 patients who met the inclusion criteria and underwent laparoscopic sleeve gastrectomy in the general surgery clinic of a university hospital between December 2022 and October 2023. Data were collected using the 'Perioperative Form,' 'Visual Analog Scale,' and 'State Anxiety Scale I-II.' Intervention group patients were informed and educated about the surgical process in the outpatient clinic. The anxiety levels of all patients were determined with the State Anxiety Scale the day before surgery. In the postoperative period, vital signs (once), anxiety (on the first day after surgery), and pain levels (eight times during 48 h) were measured. RESULTS: In the analysis between the groups, the difference between the duration of postoperative hospital stay (p = 0.007), pain (p = 0.000 for all measured), and anxiety levels (p = 0.000) was statistically significant. There were also significant differences in the diastolic blood pressure (p = 0.007), body temperature (p = 0.000), and saturation values (p = 0.000). Patients' readiness level for surgery was the most influential factor in postoperative pain levels (p = 0.000). CONCLUSION: The education given to the patients before hospitalization decreased preoperative and postoperative anxiety levels, postoperative hospital stay and pain levels, and positively affected diastolic blood pressure, body temperature and saturation levels. One-to-one education given to patients in the outpatient clinic also contributes positively to their readiness for surgery. This study provides valuable evidence to the wider global clinical community by demonstrating the important benefits of preadmission education for patients undergoing bariatric surgery. Implementation of similar educational interventions in diverse healthcare settings worldwide may lead to increased postoperative recovery and improved overall patient well-being after bariatric surgery.

Assessing the Risk of Postoperative Delirium Through Comprehensive Geriatric Assessment and Eastern Cooperative Oncology Group Performance Status of Elderly Patients With Gastric Cancer.

BACKGROUND: Postoperative delirium is especially common and often problematic among elderly patients undergoing surgery. This study aimed to explore factors that can predict postoperative delirium in elderly patients undergoing gastric cancer surgery. METHODS: This cohort study included 255 patients age 75 years or older who underwent gastric cancer surgery between July 2010 and December 2020. All the patients underwent preoperative comprehensive geriatric assessment (CGA) evaluation by a geriatrician. In addition to the CGA items, this study investigated the association between postoperative delirium and clinicopathologic factors, including Eastern Cooperative Oncology Group performance status (ECOG-PS). RESULTS: The most common postoperative complication was delirium, present in 31 patients (12.2%). The group with delirium was significantly more likely to have ECOG-PS ≥ 2, diabetes mellitus, cardiovascular disease, or cerebral infarction. The CGA showed frailty in the Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), the Vitality Index (VI), and the Geriatric Depression Scale 15 (GDS-15). In the multivariate analysis, the independent risk factors for delirium were ECOG-PS ≥ 2 (P = 0.002) and MMSE-frailty (P < 0.001). Using an MMSE score of ≤ 23 and an ECOG-PS score of ≥ 2 as cutoffs, postoperative delirium was predicted with a sensitivity of 80.7% and a specificity of 74.1%. CONCLUSION: Postoperative delirium might be more easily predicted based on the combination of MMSE and ECOG-PS for elderly patients with gastric cancer undergoing gastrectomy.

Impact of infectious complications after gastrectomy on non­gastric cancer­related deaths.

Infectious complications (ICs) have been reported as major causes of postoperative mortality in patients with cancer. However, to the best of our knowledge, the impact of ICs after gastrectomy on non-gastric cancer-related deaths (NGCDs) remains unexplored. The present study aimed to identify the impact of ICs after gastrectomy on NGCDs. A retrospective analysis of 712 patients with gastric cancer who underwent curative gastrectomy was conducted. The participants were categorized into IC and non-IC groups based on the incidence of postoperative IC. Clinicopathological factors and non-gastric cancer-related survival (NGCS) rates were compared between groups. Further NGCD and associated risk factor analyses were performed in a background factor-adjusted cohort using multivariate analysis. Among the 712 patients, 112 developed ICs (Clavien-Dindo classification grade ≥II). In the entire cohort, the IC group had a significantly worse 5-year cumulative incidence of NGCD (17.8 vs. 10.6%; Gray's P=0.021) compared with the non-IC group. Although a number of clinicopathological factors differed between the groups, including patient background, operative factors and tumor factors, the risk factors for NGCD identified in the multivariate analysis were older age, low prognostic nutritional index, low skeletal muscle index and Charlson comorbidity index ≥1, excluding IC incidents. The IC group exhibited more background factors contributing to NGCDs, suggesting a potential increase in NGCD regardless of IC incidence.

Proficiency in bariatric surgery may shorten the learning curve for minimally-invasive D2 gastrectomy.

INTRODUCTION: Evidence from Asian studies suggests that minimally-invasive gastrectomy achieves equivalent oncological but improved perioperative outcomes compared to open surgery. Oncological gastric resections are less frequent in European countries. Index procedures may play a role for the learning curve of minimally-invasive gastrectomy. The aim of our study was to evaluate if skills acquired in bariatric surgery allow a safe and oncologically adequate implementation of minimally-invasive gastrectomy in a cohort of european patients. METHODS: In this single-center retrospective study, all patients who received primary bariatric surgery between January 2015 and December 2018 and minimally-invasive surgery for gastric cancer treated from June 2019 to January 2023 were evaluated. Primary endpoints were operation time, lymph node yield and lymph node fractions. Secondary endpoints included postoperative complications and oncological outcomes. RESULTS: Learning curves for two surgeons with 350 bariatric procedures and 44 minimally-invasive gastrectomies were analyzed. For bariatric surgery, the mean operation time decreased from initially 82 ± 27 to 45 ± 21 min and 118 ± 28 to 81 ± 36 min for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), while the complication rate remained within the international benchmark. For laparoscopic gastrectomy (n = 30), operation times decreased but then remained stable over time. Operation times for the robotic platform were longer (302 ± 60 vs. 390 ± 48 min; p < 0.001) with the learning curve remaining incomplete after 14 procedures. R0 status was achieved in 95.5% of patients; the mean number of lymph nodes retrieved was 37 ± 14 with no differences between the groups. Complete mesogastric excision was more frequently achieved during the later laparoscopic cases whereas it occurred earlier for the robotic group (p = 0.004). Perioperative morbidity was comparable to the European benchmark. Textbook outcome was achieved in 54.4% of the cases. CONCLUSION: In summary, we could demonstrate a successful skill transfer from bariatric surgery to minimally-invasive laparoscopic oncological gastric surgery enabling safe and oncologically adequate minimally-invasive D2 gastrectomy in a central European patient collective.

The effect of laparoscopic vertical sleeve gastrectomy and laparoscopic roux-en-Y gastric bypass on gastroesophageal reflux disease: An updated meta-analysis and systematic review of 5-year post-operative data from randomized controlled trials.

BACKGROUND: To evaluate 5-year effect of laparoscopic vertical sleeve gastrectomy (LVSG) versus laparoscopic roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) solely based on randomized controlled trials (RCTs). METHODS: A systematic review and meta-analysis of 5-year postoperative GERD data comparing LVSG and LRYGB in adults were undertaken. Electronic databases were searched from January 2015 to March 2024 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was applied to estimate pooled odds ratio where meta-analysis was possible. Bias and certainty of evidence were assessed using the Cochrane Risk of Bias Tool 2 and GRADE. RESULTS: Five RCTs were analysed (LVSG n = 554, LRYGB n = 539). LVSG was associated with increased adverse GERD outcomes compared to LRYGB at 5 years. The odds for revisional surgery to treat GERD in LVSG patients were 11 times higher compared to LRYGB (OR 11.47, 95% CI 1.83 to 71.69; p = 0.02; I2 = 0% High level of certainty). Similarly pharmacological management for increasing GERD was significantly more frequent in LVSG patients compared to LRYGB (OR 3.89, 95% CI 2.31 to 6.55; p ≤ 0.01; I2 = 0% Moderate level of certainty). Overall, LVSG was associated with significantly more interventions (both medical and surgical) for either worsening GERD and/or development of de novo GERD compared to LRYGB (OR 5.98, 95% CI 3.48 to 10.29; p ≤ 0.01; I2 = 0%) Moderate level of certainty). CONCLUSIONS: The development and worsening of GERD symptoms are frequently associated with LVSG compared to LRYGB at 5 years postoperatively requiring either initiation or increase of pharmacotherapy or failing that revisional bariatric surgery. Appropriate patient/surgical selection is crucial to reduce these postoperative risks of GERD.

A case report of colon interposition radical surgery performed via unilateral thoracotomy in a patient with esophageal cancer after billroth II gastrectomy.

Introduction: When a gastric tube cannot be used as a substitute for the esophagus, the colon offers several advantageous features for esophageal replacement. However, this procedure remains complex and necessitates patients to have a favorable nutritional status. In this study, we investigated the viability of intrathoracic colonic interposition anastomosis through a single thoracic incision, with the goal of mitigating surgical challenges and nutritional requirements. Case description: We conducted a colectomy and reconstructed the esophageal-colonic-gastric tract via the esophageal bed into the left thoracic cavity for a 68-year-old male patient with compromised nutritional status following 30 years post-Billroth II (BII) gastrectomy. Under normal circumstances, this patient would not have been deemed an appropriate candidate for a conventional colonic interposition procedure. The patient resumed a soft diet through the normal digestive tract two weeks after the surgery and was discharged 20 days later. Conclusion: Patients who have previously received a Billroth II Gastrectomy and subsequently developed early-stage esophageal cancer, characterized by the absence of lymph node metastasis, are suitable candidates for Colon Interposition Radical Surgery via left thoracotomy.