Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Is Intrathoracic Migration of the Sleeve of High Incidence?

BACKGROUND: Conversion of SG to Roux-en-Y gastric bypass (RYGB) is increasing. Intrathoracic migration of the sleeve (ITM) often seems associated and is increasingly reported. MATERIAL AND METHODS: Patients who underwent a conversion of SG to RYGB from August 2013 to December 2022 were included. Two groups were compared: patients operated on for weight loss failure (WLF gp) and those operated on for gastroesophageal reflux disease (GERD gp). Demographic data, the incidence of ITM, weight loss outcomes, resolution of symptoms, and morbidity were analyzed. RESULTS: Fifty-nine patients were included with an average follow-up of 32 months: 46 patients in the GERD gp (78%) were compared to 13 patients (22%) in the WLF gp. Groups were comparable regarding age and gender, but BMI and commodities were significantly higher in the WLF gp. In the GERD gp, on preoperative gastroscopy, 30% had a esophagitis, 48% had an ITM which required a posterior crural closure versus no esophagitis (p=0.02) and 23% of ITM in the WLF gp (p=0.11). Conversion led to 93% of GERD symptom improvement. In the WLF gp, mean TWL% was 15.3%, significantly greater than in the GERD gp (TWL% = 4.6%, p = 0.01). The complication rate was 10% at 30 days and 3.4% after 30 days, not significantly different between groups. CONCLUSION: The main indication of conversion of SG to RYGB was because of GERD: in these indications, the incidence of ITM was high requiring a surgical treatment with a very good efficacy on symptoms. Weight loss results were disappointing.

Predicting Inadequate Weight Loss After Bariatric Surgery: Derivation and Validation of a Four Factor Model.

INTRODUCTION: Weight loss following bariatric surgery is variable and predicting inadequate weight loss is required to help select patients for bariatric surgery. The aim of the present study was to determine variables associated with inadequate weight loss and to derive and validate a predictive model. METHODS: All patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastrectomy (2008-2022) in a tertiary referral centre were followed up prospectively. Inadequate weight loss was defined as excess weight loss (EWL) < 50% by 24 months. A top-down approach was performed using multivariate logistic regression and then internally validated using bootstrapping. Patients were categorised into risk groups. RESULTS: A total of 280 patients (median age, 49 years; M:F, 69:211) were included (146 LSG; 134 LRYGB). At 24 months, the median total weight loss was 30.9% and 80.0% achieved EWL ≥ 50% by 24 months. Variables associated with inadequate weight loss were T2DM (OR 2.42; p = 0.042), age 51-60 (OR 1.93, p = 0.006), age > 60 (OR 4.93, p < 0.001), starting BMI > 50 kg/m² (OR 1.93, p = 0.037) and pre-operative weight loss (OR 3.51; p = 0.036). The validation C-index was 0.75 (slope = 0.89). Low, medium and high-risk groups had a 4.9%, 16.7% and 44.6% risk of inadequate weight loss, respectively. CONCLUSIONS: Inadequate weight loss can be predicted using a four factor model which could help patients and clinicians in decision-making for bariatric surgery.

Cost-Effectiveness of Laparoscopic Sleeve Gastrectomy for Chinese Patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery procedure in China. However, its cost-effectiveness in Chinese patients is currently unknown. OBJECTIVES: This study aims to assess the cost-effectiveness of LSG vs no surgery in Chinese patients with severe and complex obesity, taking into account both healthcare expenses and the potential improvement in health-related quality of life (HRQoL). METHODS: A retrospective cohort study was conducted, encompassing 135 Chinese patients who underwent LSG between January 3, 2022 and December 29, 2022, at a major bariatric center. The study evaluated the cost-effectiveness from a healthcare service perspective, employing the incremental cost-effectiveness ratio (ICER) for quality-adjusted life years (QALYs) gained. The analyses compared LSG with the alternative of not undergoing surgery over a 1-year period, using actual data, and extended to a lifetime horizon by projecting costs and utilities at an annual discount rate of 3.0%. Subgroup analyses were undertaken to explore cost-effectiveness variations across different sex, age and BMI categories, and diabetes status, employing a one-way analysis of variance (ANOVA). To ensure the reliability of the findings, one-way and probabilistic sensitivity analyses were executed. RESULTS: The results indicated that 1-year post-LSG, patients achieved an average total weight loss (TWL) of (32.7 ± 7.3)% and an excess weight loss (EWL) of (97.8 ± 23.1)%. The ICER for LSG compared to no surgery over a lifetime was $4,327/QALY, significantly below the willingness-to-pay (WTP) threshold for Chinese patients with severe and complex obesity. From a lifetime perspective, LSG proved to be cost-effective for all sex and age groups, across all BMI categories, and for both patients with and without diabetes. Notably, it was more cost-effective for younger patients, patients with higher BMI, and patients with diabetes. CONCLUSIONS: LSG is a highly cost-effective intervention for managing obesity in Chinese patients, delivering substantial benefits in terms of HRQoL improvement at a low cost. Its cost-effectiveness is particularly pronounced among younger individuals, those with higher BMI, and patients with diabetes.

Lung ultrasound score evaluation of the effect of pressure-controlled ventilation volume-guaranteed on patients undergoing laparoscopic-assisted radical gastrectomy.

BACKGROUND: Laparoscopic-assisted radical gastrectomy (LARG) is the standard treatment for early-stage gastric carcinoma (GC). However, the negative impact of this procedure on respiratory function requires the optimized intraoperative management of patients in terms of ventilation. AIM: To investigate the influence of pressure-controlled ventilation volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) on blood gas analysis and pulmonary ventilation in patients undergoing LARG for GC based on the lung ultrasound score (LUS). METHODS: The study included 103 patients with GC undergoing LARG from May 2020 to May 2023, with 52 cases undergoing PCV-VG (research group) and 51 cases undergoing VCV (control group). LUS were recorded at the time of entering the operating room (T0), 20 minutes after anesthesia with endotracheal intubation (T1), 30 minutes after artificial pneumoperitoneum (PP) establishment (T2), and 15 minutes after endotracheal tube removal (T5). For blood gas analysis, arterial partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) were observed. Peak airway pressure (Ppeak), plateau pressure (Pplat), mean airway pressure (Pmean), and dynamic pulmonary compliance (Cdyn) were recorded at T1 and T2, 1 hour after PP establishment (T3), and at the end of the operation (T4). Postoperative pulmonary complications (PPCs) were recorded. Pre- and postoperative serum interleukin (IL)-1ß, IL-6, and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay. RESULTS: Compared with those at T0, the whole, anterior, lateral, posterior, upper, lower, left, and right lung LUS of the research group were significantly reduced at T1, T2, and T5; in the control group, the LUS of the whole and partial lung regions (posterior, lower, and right lung) decreased significantly at T2, while at T5, the LUS of the whole and some regions (lateral, lower, and left lung) increased significantly. In comparison with the control group, the whole and regional LUS of the research group were reduced at T1, T2, and T5, with an increase in PaO2, decrease in PaCO2, reduction in Ppeak at T1 to T4, increase in Pmean and Cdyn, and decrease in Pplat at T4, all significant. The research group showed a significantly lower incidence of PPCs than the control group within 3 days postoperatively. Postoperative IL-1ß, IL-6, and TNF-α significantly increased in both groups, with even higher levels in the control group. CONCLUSION: LUS can indicate intraoperative non-uniformity and postural changes in pulmonary ventilation under PCV-VG and VCV. Under the lung protective ventilation strategy, the PCV-VG mode more significantly improved intraoperative lung ventilation in patients undergoing LARG for GC and reduced lung injury-related cytokine production, thereby alleviating lung injury.

Comparison efficacy and safety of total laparoscopic gastrectomy and laparoscopically assisted total gastrectomy in treatment of gastric cancer.

BACKGROUND: The development of laparoscopic technology has provided a new choice for surgery of gastric cancer (GC), but the advantages and disadvantages of laparoscopic total gastrectomy (LTG) and laparoscopic-assisted total gastrectomy (LATG) in treatment effect and safety are still controversial. The purpose of this study is to compare the efficacy and safety of the two methods in the treatment of GC, and to provide a basis for clinical decision-making. AIM: To compare the efficacy of totally LTG (TLTG) and LATG in the context of radical gastrectomy for GC. Additionally, we investigated the safety and feasibility of the total laparoscopic esophagojejunostomy technique. METHODS: Literature on comparative studies of the above two surgical methods for GC (TLTG group and LATG group) published before September 2022 were searched in the PubMed, Web of Science, Wanfang Database, CNKI, and other Chinese and English databases. In addition, the following search keywords were used: Gastric cancer, total gastrectomy, total laparoscopy, laparoscopy-assisted, esophagojejunal anastomosis, gastric/stomach cancer, total gastrectomy, totally/completely laparoscopic, laparoscopic assisted/laparoscopy assisted/laparoscopically assisted, and esophagojejunostomy/esophagojejunal anastomosis. Review Manager 5.3 software was used for the meta-analysis after two researchers independently screened the literature, extracted the data, and evaluated the risk of bias in the included studies. RESULTS: After layer-by-layer screening, 258 pieces of literature were recovered, and 11 of those pieces were eventually included. This resulted in a sample size of 2421 instances, with 1115 cases falling into the TLTG group and 1306 cases into the LATG group. Age or sex differences between the two groups were not statistically significant, according to the meta-analysis, however the average body mass index of the TLTG group was considerably higher than that of the LATG group (P = 0.01). Compared with those in the LATG group, the incision length in the TLTG group was significantly shorter (P < 0.001), the amount of intraoperative blood loss was significantly lower (P = 0.003), the number of lymph nodes removed was significantly greater (P = 0.04), and the time of first postoperative feeding and postoperative hospitalization were also significantly shorter (P = 0.03 and 0.02, respectively). There were no significant differences in tumor size, length of proximal incisal margin, total operation time, anastomotic time, postoperative pain score, postoperative anal exhaust time, postoperative anastomosis-related complications (including anastomotic fistula, anastomotic stenosis, and anastomotic hemorrhage), or overall postoperative complication rate (P > 0.05). CONCLUSION: TLTG and esophagojejunostomy are safe and feasible. Compared with LATG, TLTG has the advantages of less trauma, less bleeding, easier access to lymph nodes, and faster postoperative recovery, and TLTG is also suitable for obese patients.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopic-assisted total gastrectomy.

BACKGROUND: Natural orifice specimen extraction surgery (NOSES) has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy (LATG) for treating gastric cancer (GC). However, evidence regarding the efficacy and safety of NOSES for GC surgery is limited. This study aimed to compare the safety and feasibility, in addition to postoperative complications of NOSES and LATG. AIM: To discuss the postoperative effects of two different surgical methods in patients with GC. METHODS: Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG, and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size ≤ 5 cm. The study was conducted from May 2018 to September 2020, and patients were categorized into the NOSES group (n = 22) and LATG group (n = 29). Perioperative parameters were compared and analyzed, including patient and tumor characteristics, postoperative outcomes, and anastomosis-related complications, postoperative hospital stay, the length of abdominal incision, difference in tumor type, postoperative complications, and postoperative survival. RESULTS: Postoperative exhaust time, operation duration, mean postoperative hospital stay, length of abdominal incision, number of specific staplers used, and Brief Illness Perception Questionnaire score were significant in both groups (P < 0.01). In the NOSES group, the postoperative time to first flatus, mean postoperative hospital stay, and length of abdominal incision were significantly shorter than those in the LATG group. Patients in the NOSES group had faster postoperative recovery, and achieved abdominal minimally invasive incision that met aesthetic requirements. There were no significant differences in gender, age, tumor type, postoperative complications, and postoperative survival between the two groups. CONCLUSION: The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient. This approach offers better short-term outcomes compared to LATG, while long-term survival rates are comparable to those of conventional laparoscopic surgery.

An Inflammatory Fibroid Polyp of the Stomach.

An inflammatory fibroid polyp (Vanek's polyp) is a rare, benign, mesenchymal polyp originating from the submucosa of the gastrointestinal tract. Symptoms are non-specific and depend on the tumor size and location. Despite their benign nature, these tumors can mimic other malignant conditions, making an accurate diagnosis crucial for appropriate management. Histologically, they are submucosal lesions composed of spindle-shaped or stellate stromal cells, stroma with thin-walled vessels around which spindle-shaped cells are arranged similar to onion skin, an eosinophil-rich inflammatory infiltrate, and minimal mitotic activity. In this article, we present the case of a 63-year-old woman with a giant benign inflammatory fibroid polyp of the stomach. We performed distal esophageal resection, total gastrectomy, and omentectomy, as the passage was restored with a transmesocolic termino-lateral esophago-jejunal Roux-en-Y anastomosis. We also present a brief literature review on this topic.

Effects of buccal acupuncture on postoperative analgesia in elderly patients undergoing laparoscopic radical gastrectomy: a randomized controlled trial.

Objective: This study aimed to evaluate the efficacy and safety of buccal acupuncture on postoperative analgesia, perioperative stress response and adverse events in elderly patients undergoing laparoscopic radical gastrectomy. Methods: It was a prospective, outcome assessor-blinded, randomized controlled trial, involving 90 patients aged 65-80 years who were treated with an elective laparoscopic radical gastrectomy. They were randomly assigned to buccal acupuncture group (Group B) and control group (Group C). Buccal acupuncture was applied to patients of Group B before the induction of general anesthesia, while no additional application was given to those in Group C. Patient-controlled intravenous analgesia (PCIA) with sufentanil was postoperatively performed in both groups. Sufentanil consumption and the Visual Analog Scale (VAS) score within 48 h postoperatively were assessed as primary outcomes. Secondary outcomes included peripheral levels of stress markers, intraoperative consumptions of anesthetic drugs and postoperative recovery. Results: Patients in Group B presented significantly lower VAS scores within 24 h and less consumption of sufentanil within 48 h postoperatively (both p < 0.01). The awaking time, time to extubation and length of stay were significantly shorter in Group B than in Group C (p = 0.005, 0.001 and 0.028, respectively). Compared with Group C, stress response and inflammatory response within 24 h postoperatively were also significantly milder in Group B. Conclusion: The use of buccal acupuncture before general anesthesia induction favors the postoperative analgesic effect and recovery in elderly patients undergoing laparoscopic radical gastrectomy, the mechanism of which involves relieving postoperative stress response and inflammatory response. Clinical trial registration: This study was registered in the Chinese Clinical Trial Registry (www.chictr.org.cn) on 15/06/2023 (ChiCTR2300072500).

Feasibility of Narrow-Spectrum Antimicrobial Agents for Post-Operative Intra-Abdominal Infections After Gastrectomy.

Introduction: Recently, antimicrobial resistance has received considerable attention. Broad-spectrum antimicrobial agents are recommended as the initial therapy for post-operative intra-abdominal infections. However, at our institution, we have adopted a tactic of initially treating post-operative intra-abdominal complications with relatively narrow-spectrum antimicrobial agents, such as second-generation cephalosporins. In the present study, we aimed to retrospectively analyze the use of antimicrobial agents and the resulting treatment outcomes in patients with intra-abdominal complications after gastrectomy at our facility. Methods: We conducted a retrospective observational study of patients treated with antibiotic agents for intra-abdominal infectious complications after gastrectomy between 2011 and 2021. We determined the proportion of "initial treatment failures" associated with the initial administration of antibiotic agents for post-operative intra-abdominal complications. Results: Post-operative intra-abdominal infections were observed in 29 patients. Broad-spectrum antimicrobial agents were not administered. We successfully treated 19 patients. Initial treatment failure was observed in 10 patients, of whom five experienced failure due to bacterial resistance to the initial antimicrobial agent. All 10 patients who experienced initial treatment failure were discharged after drainage procedures or other treatments. There were no deaths due to post-operative complications. Cefmetazole was used as the initial antimicrobial agent in 27 of the 29 patients. Conclusions: Considering that all patients with post-gastrectomy intra-abdominal infections were successfully treated using relatively narrow-spectrum antimicrobial agents, and initial treatment failure due to antimicrobial-resistant pathogens was 17.2%, the use of narrow-range antimicrobial agents for intra-abdominal infections after gastrectomy can be deemed appropriate.

The real occurrence of gastroesophageal reflux disease after sleeve gastrectomy - a prospective pH-monitoring study.

Introduction: Sleeve gastrectomy (SG) is currently the most frequently performed bariatric procedure in the world. However, the occurrence of gastroesophageal reflux disease (GERD) after SG remains controversial and questionable. Aim: To determine the occurrence of GERD after SG using a pH-monitoring study. Material and methods: This is a prospective study involving patients undergoing SG in one surgical centre. Inclusion criteria were eligibility for bariatric surgery, no symptoms of GERD, normal gastroscopy, and pH-monitoring before the surgery. Postoperative examinations were performed 6 months after surgery. Results: A total of 38 patients were analysed in the study. The mean age was 44.9 years, and the mean preoperative BMI was 42.6 kg/m2. Before surgery, all patients had normal pH values. After surgery, mean acid exposure time (AET), number of refluxes, and DeMeester score increased statistically significantly (p < 0.001). 27 (71.1%) patients each had AET > 6%, but only 9 (23.7%) reported GERD symptoms and the need for PPIs. The correlation between AET and %TWL was moderate positive, and the correlation between DeMeester score and %TWL was low positive (p = 0.011, p = 0.014, respectively). Conclusions: GERD after SG seems to be a significant problem. More than two-thirds of patients had de novo GERD after SG in pH-monitoring, but only one-quarter of them required PPIs.

Endoscopic sleeve gastroplasty safety profile - retrospective, single-center analysis of 222 consecutive patients including the learning curve period.

Introduction: The global obesity epidemic affects over 1.9 billion adults, with an additional 650 million classified as obese. Endoscopic sleeve gastroplasty (ESG) is a type of minimally invasive endobariatric procedure. It is a less invasive alternative to laparoscopic sleeve gastrectomy (LSG). Although the effectiveness of ESG is lower, it might have a better safety profile. Aim: To assess the safety profile of ESG and describe complications classified as grade II or higher, using the Clavien-Dindo classification, with an overview of the learning curve. Material and methods: We included 222 patients who underwent ESG at the Endoscopic and Bariatric Surgery Center of the hospital in Brzeziny from January 2021 to October 2023. The severity of complications was evaluated based on the Clavien-Dindo classification, considering complications of grade II or higher. Results: Among the studied group of patients, a total of 4 (1.8%) cases of perioperative bleeding into the gastrointestinal tract were recorded. One (0.5%) patient had the most severe grade IVb complication that required treatment in the Intensive Care Unit. All patients with serious adverse events (SAE) fully recovered. We did not observe an association between the learning curve, procedure duration, and the frequency or severity of postoperative complications. Conclusions: The presented results confirm the high safety of ESG in the treatment of obesity.

Massive Gastric Juvenile Polyposis Associated With Intermittent Gastric Outlet Obstruction: A Case Report.

Juvenile polyposis syndrome is a condition distinguished by numerous hyperproliferative polyps that can affect the entire gastrointestinal tract, though they are uncommon in the stomach. We report a rare case of a 70-year-old woman with a three-year history of epigastric pain and severe bloating who was referred to our department for gastric outlet obstruction due to massive gastric juvenile polyps also causing gastroparesis. The patient was successfully treated with a total gastrectomy.

Predictive modeling of lower extreme deep vein thrombosis following radical gastrectomy for gastric cancer: based on multiple machine learning methods.

Postoperative venous thromboembolic events (VTEs), such as lower extremity deep vein thrombosis (DVT), are major risk factors for gastric cancer (GC) patients following radical gastrectomy. Accurately predicting and managing these risks is crucial for optimal patient care. This retrospective case‒control study involved 693 GC patients from our hospital who underwent radical gastrectomy. We collected plentiful and comprehensive clinical indicators including a total of 49 baseline, preoperative, surgical and pathological clinical data. Using univariate logistic regression, we identified potential risk factors, followed by feature selection through the Boruta algorithm. We then constructed the final predictive model using multivariate logistic regression and evaluated it using receiver operating characteristic (ROC) curve analysis, calibration plots, decision curve analysis, and other methods. Additionally, we applied various machine learning techniques, including decision trees and random forests, to assess our model's predictive strength. This retrospective case‒control study involved 693 GC patients from our hospital who underwent radical gastrectomy. We collected plentiful and comprehensive clinical indicators including a total of 49 baseline, preoperative, surgical and pathological clinical data. Using univariate logistic regression, we identified potential risk factors, followed by feature selection through the Boruta algorithm. We then constructed the final predictive model using multivariate logistic regression and evaluated it using receiver operating characteristic (ROC) curve analysis, calibration plots, decision curve analysis, and other methods. Additionally, we applied various machine learning techniques, including decision trees and random forests, to assess our model's predictive strength. Univariate logistic analysis revealed 14 risk factors associated with postoperative lower limb DVT. Based on the Boruta algorithm, six significant clinical factors were selected, namely, age, D-dimer (D-D) level, low-density lipoprotein, CA125, and calcium and chloride ion levels. A nomogram was developed using the outcomes from the multivariate logistic regression analysis. The predictive model showed high accuracy, with an area under the curve of 0.936 in the training set and 0.875 in the validation set. Various machine learning algorithms confirmed its strong predictive capacity. MR analysis revealed meaningful causal relationships between key clinical factors and DVT risk. Based on various machine learning methods, we developed an effective predictive diagnostic model for postoperative lower extremity DVT in GC patients. This model demonstrated excellent predictive value in both the training and validation sets. This novel model is a valuable tool for clinicians to use in identifying and managing thrombotic risks in this patient population.

Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series.

BACKGROUND: This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan). METHODS: We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction. RESULTS: Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days. CONCLUSION: In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Risk factors of postoperative complications and their effect on survival after laparoscopic gastrectomy for gastric cancer.

Background: The association between postoperative complications and long-term survival after laparoscopic gastrectomy (LG) for gastric cancer (GC) remains uncertain. This study aimed to determine the incidence and risk factors of postoperative complications and evaluate their impact on survival outcomes in patients undergoing LG. Methods: A retrospective study was conducted on 621 patients who underwent LG for gastric adenocarcinoma between March 2015 and December 2021. Postoperative complications were classified according to the Clavien-Dindo classification, with major complications defined as Grade III or higher. Logistic regression models with stepwise backward procedure were used to identify risk factors for complications. To assess the impact of postoperative complications on survival, uni- and multi-variable Cox proportional hazard models were used for overall survival (OS) and disease-free survival (DFS). Results: Overall rate of postoperative complications was 17.6% (109 patients); 33 patients (5.3%) had major complications. Independent risk factors for major complications were Charlson comorbidities index (OR [95% CI], 1.87 [1.09-3.12], p-value = 0.018 for each one score increase), and type of anastomosis (OR [95% CI], 0.28 [0.09-0.91], p-value = 0.029 when comparing Billroth II with Billroth I). Multivariable analysis identified major complications as an independent prognostic factor to reduce OS (HR [95% CI], 2.32 [1.02-5.30], p-value = 0.045) and DFS (HR [95% CI], 2.63 [1.37-5.06], p-value = 0.004). Other prognostic factors for decreased survival outcomes were tumor size, presence of invasive lymph nodes, and T4a stage. Conclusions: Major complications rate of LG for GC was approximately 5.3%. Charlson comorbidities index and type of anastomosis were identified as risk factors for major postoperative complications. Major complications were demonstrated to pose adverse impact on survival outcomes.

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer.

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Identification of the factor affecting learning curves of laparoscopic gastrectomy through the experience at a Japanese high-volume center over the last decade.

Background: Though laparoscopic gastrectomy (LG) has become the gold standard for gastric cancer treatment according to the Japanese treatment guidelines, its learning curve remains steep. Decreasing numbers of surgeons and transitions in the work environment have changed LG training recently. We analyzed LG training over the last decade to identify factors affecting the learning curve. Study Design: Laparoscopic distal and pylorus-preserving gastrectomies conducted between 2010 and 2020 were included. We assessed learning curves based on the standard operation time (SOT) defined by analysis of covariance. Then we divided the trainees into two groups based on the length of the learning curve and examined the factors affecting the learning curve with linear regression analysis. Results: Among 2335 LGs, 960 cases treated by 27 trainees and 1301 cases treated by six attending surgeons were analyzed. The operation time was prolonged (p = 0.009) and postoperative morbidity rates were lower (p = 0.0003) for cases treated by trainees. Trainees experienced 38 (range, 9-81) cases as scopists and nine (range, 0-41) cases as first assistants to the first operator. The learning curve was approximately 30 cases. The SOT was calculated based on gender, body mass index, tumor location, reconstruction, and lymph node dissection. Trainees who had shorter learning curves had more experience (51-100 cases) with any laparoscopic surgery before LG training than the others (11-50 cases, p = 0.017). Conclusion: Sufficient experience with laparoscopic surgery before starting LG training might contribute to the efficiency of LG training and shorten the learning curve.

Evaluating surgical expertise with AI-based automated instrument recognition for robotic distal gastrectomy.

Introduction: Complexities of robotic distal gastrectomy (RDG) give reason to assess physician's surgical skill. Varying levels in surgical skill affect patient outcomes. We aim to investigate how a novel artificial intelligence (AI) model can be used to evaluate surgical skill in RDG by recognizing surgical instruments. Methods: Fifty-five consecutive robotic surgical videos of RDG for gastric cancer were analyzed. We used Deeplab, a multi-stage temporal convolutional network, and it trained on 1234 manually annotated images. The model was then tested on 149 annotated images for accuracy. Deep learning metrics such as Intersection over Union (IoU) and accuracy were assessed, and the comparison between experienced and non-experienced surgeons based on usage of instruments during infrapyloric lymph node dissection was performed. Results: We annotated 540 Cadiere forceps, 898 Fenestrated bipolars, 359 Suction tubes, 307 Maryland bipolars, 688 Harmonic scalpels, 400 Staplers, and 59 Large clips. The average IoU and accuracy were 0.82 ± 0.12 and 87.2 ± 11.9% respectively. Moreover, the percentage of each instrument's usage to overall infrapyloric lymphadenectomy duration predicted by AI were compared. The use of Stapler and Large clip were significantly shorter in the experienced group compared to the non-experienced group. Conclusions: This study is the first to report that surgical skill can be successfully and accurately determined by an AI model for RDG. Our AI gives us a way to recognize and automatically generate instance segmentation of the surgical instruments present in this procedure. Use of this technology allows unbiased, more accessible RDG surgical skill.

Timing Considerations for Sleeve Gastrectomy in Kidney Transplant Patients: A Single Center Evaluation.

Current scientific literature is deficient in detailing the optimal timing for conducting bariatric surgery in relation to kidney transplantation. In this study, we performed a retrospective evaluation of kidney transplant recipients with BMI >35 kg/m2. It aimed to provide data on those who received both sleeve gastrectomy (SG) and kidney transplantation (KT) simultaneously, as well as on patients who underwent SG and KT at different times, either before or after. In addition, the acceptance levels of the bariatric surgery among different scenarios were assessed. Our findings demonstrated that combined KT and SG led to successful weight loss, in contrast to undergoing kidney transplant alone, while maintaining comparable rates of graft and patient survival. Weight loss was similar between recipients who had a combined operation and those who underwent SG following the transplant. Additionally, over a median time frame of 1.7 years, patients who underwent SG before KT exhibited a statistically significant reduction in BMI at the time of the transplant. Notably, our study highlights that patients offered the combined procedure were significantly more likely to undergo SG compared to those for whom SG was presented at a different operative time than the transplant.

The Potential Mechanism of Remission in Type 2 Diabetes Mellitus After Vertical Sleeve Gastrectomy.

In recent years, there has been a gradual increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), with bariatric surgery remaining the most effective treatment strategy for these conditions. Vertical sleeve gastrectomy (VSG) has emerged as the most popular surgical procedure for bariatric/metabolic surgeries, effectively promoting weight loss and improving or curing T2DM. The alterations in the gastrointestinal tract following VSG may improve insulin secretion and resistance by increasing incretin secretion (especially GLP-1), modifying the gut microbiota composition, and through mechanisms dependent on weight loss. This review focuses on the potential mechanisms through which the enhanced action of incretin and metabolic changes in the digestive system after VSG may contribute to the remission of T2DM.