Colorectal stent placement assisted by a slim gastroscope: technique and outcomes.

BACKGROUND: The distorted anatomy in patients with obstruction renders colon stent placement difficult. Here, we propose two novel techniques for stent implantation. METHODS: Patients in whom there was difficulty placing the guidewire with the normal method were retrospectively included in our study. All of the patients underwent the technique of combining a slim gastroscope with a normal colonoscope. We assessed the technical success, clinical success, and adverse events associated with self-expanding metal stent placement. RESULTS: From June 2018 to June 2020, 30.5% of patients with difficult catheterization were included in this study. Finally, stents in 17 of 18 patients (3 rectum, 13 sigmoid colon, 1 descending colon, and 1 hepatic flexure) (94.4%) were placed successfully, assisted by a slim gastroscope with or without radiography, and the obstruction was relieved. Only one remaining patient experienced failure. No intraoperative or 30-day postoperative morbidity or mortality was observed. CONCLUSION: The present study showed that the stent implantation technique assisted by a slim gastroscope combined with a normal colonoscope was a relatively safe and effective method for abolishing difficult intestinal stenosis. More studies are needed to compare the advantages and disadvantages of this technique with normal endoscopic implantation.

Improving All-Cause Inpatient Mortality After Percutaneous Endoscopic Gastrostomy.

BACKGROUND AND AIMS: Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients. METHODS: A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample. RESULTS: A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201). CONCLUSIONS: Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement.

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Recurrence Patterns and Outcomes of Salvage Surgery in Cases of Non-Curative Endoscopic Submucosal Dissection without Additional Radical Surgery for Early Gastric Cancer.

BACKGROUND/AIMS: The outcomes of salvage surgery for recurrence after non-curative endoscopic submucosal dissection (ESD) without additional radical surgery for early gastric cancer (EGC) remain unclear. We determined the recurrence patterns and outcomes of salvage surgery in such cases using data from a multicenter, retrospective study. METHODS: Of 15,785 patients who underwent ESD for EGC at 19 participating institutions between January 2000 and August 2011, 1,969 failed to meet the current curative criteria after ESD. Of these, 905 patients received no additional treatment. We evaluated the pattern of recurrence, clinical course after salvage surgery, and long-term survival rate for these patients. RESULTS: Over a median 64-month follow-up period, recurrence was detected in 27 patients. Two patients with missing data were excluded. Three, seven, and 15 (60%) patients showed intragastric relapse, regional lymph node metastasis, and distant metastasis, respectively. The first line of treatment for recurrence in 1, 7, 6, and 11 patients was endoscopic treatment, salvage surgery, chemotherapy, and best supportive care, respectively. One patient survived without recurrence for 31 months after salvage surgery, one died of acute myocardial infarction 1 month after salvage surgery, and 5 showed recurrence at 0, 2, 3, 5, and 30 months after salvage surgery and eventually succumbed to the disease. The median survival times for all patients with recurrence and the 7 patients who underwent salvage surgery were 5 months after recurrence and 7 months after salvage surgery, respectively. CONCLUSION: The survival rate after salvage surgery for recurrence after non-curative ESD without additional radical surgery for EGC is quite low, with distant metastasis being the most common recurrence pattern in these cases.

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, acute and chronic complications of PEG have been reported. We aimed to determine risk factors associated with complications and 30-day mortality after PEG, based on 11 years of experience at a single tertiary hospital. METHODS: In total, 401 patients who underwent first PEG insertion at the Asan Medical Center, Seoul, Korea, between January 2005 and December 2015 were eligible. Medical records were retrospectively reviewed to determine clinical characteristics and outcomes of 139 and 262 patients who underwent pull-type and introducer-type PEG, respectively. RESULTS: The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m2. Acute and chronic complications developed in 96 (23.9%) and 105 (26.2%) patients. Acute ileus and chronic tube obstruction were significantly more frequent in the introducer-type PEG group (p = 0.033 and 0.001, respectively). The 30-day mortality rate was 5.0% (median survival: 10.5 days). Multivariate analysis revealed that underlying malignancy was a predictor of acute complications; age ≥ 70 years and diabetes mellitus were predictors of chronic complications. The median follow-up was 354 days. Neurologic disease and malignancy were the most common indications for PEG. Neurologic diseases were classified into two groups: stroke and the other neurologic disease group (including dementia, Parkinson's disease, neuromuscular disease, and hypoxic brain damage). Multivariate analysis showed that 30-day mortality was significantly lower in the other neurologic disease group and higher in patients with platelet count < 100,000/µL, and C-reactive protein (CRP) ≥ 5 mg/dL. CONCLUSIONS: PEG is a relatively safe and feasible procedure, but it was associated with significantly higher early mortality rate in patients with platelet count < 100,000/µL or CPR≥5mg/dL, and lower early mortality rate in neurologic disease group including dementia, Parkinson's disase, neuromuscular disease, and hypoxic brain damage. In addition, acute complications in patients with underlying malignancy, and chronic complications in patients aged ≥70 and those with diabetes mellitus should be considered during and after PEG.

Endoscopic full-thickness resection for gastrointestinal submucosal tumors.

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

Sentinel Node Mapping Using a Fluorescent Dye and Visible Light During Laparoscopic Gastrectomy for Early Gastric Cancer: Result of a Prospective Study From a Single Institute.

OBJECTIVE: The aim of this study was to investigate the feasibility of sentinel node mapping using a fluorescent dye and visible light in patients with gastric cancer. BACKGROUND: Recently, fluorescent imaging technology offers improved visibility with the possibility of better sensitivity or accuracy in sentinel node mapping. METHODS: Twenty patients with early gastric cancer, for whom laparoscopic distal gastrectomy with standard lymphadenectomy had been planned, were enrolled in this study. Before lymphadenectomy, the patients received a gastrofiberoscopic peritumoral injection of fluorescein solution. The sentinel basin was investigated via laparoscopic fluorescent imaging under blue light (wavelength of 440-490 nm) emitted from an LED curing light. The detection rate and lymph node status were analyzed in the enrolled patients. In addition, short-term clinical outcomes were also investigated. RESULTS: No hypersensitivity to the dye was identified in any enrolled patients. Sentinel nodes were detected in 19 of 20 enrolled patients (95.0%), and metastatic lymph nodes were found in 2 patients. The latter lymph nodes belonged to the sentinel basin of each patient. Meanwhile, 1 patient (5.0%) experienced a postoperative complication that was unrelated to sentinel node mapping. No mortality was recorded among enrolled cases. CONCLUSIONS: Sentinel node mapping with visible light fluorescence was a feasible method for visualizing sentinel nodes in patients with early gastric cancer. In addition, this method is advantageous in terms of visualizing the concrete relationship between the sentinel nodes and surrounding structures.

PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined. OBJECTIVE: To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement. MATERIALS AND METHODS: We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates. RESULTS: During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67). CONCLUSIONS: PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Surgical treatment and prognosis of gastric neuroendocrine neoplasms: a single-center experience.

BACKGROUND: Gastric neuroendocrine neoplasms (G-NENs) are uncommon, and data on their management is limited. We here investigated the clinicopathological characteristics, surgical and survival outcomes in G-NENs among Chinese. Moreover, we will discuss their prognostic value. METHODS: From existing databases of the West China Hospital, we retrospectively identified 135 consecutive patients who were surgically treated and pathologically diagnosed as G-NENs from January 2009 to August 2015. RESULTS: This entire cohort comprised 98 males and 37 females, with a median age of 60 years. Twenty-five patients underwent endoscopic resection, while 110 patients underwent open/laparoscopic surgery. Thirty-nine patients had neuroendocrine tumor G1 (NET G1), seven patients had neuroendocrine tumor G2 (NET G2), 69 patients had neuroendocrine carcinoma G3 (NEC G3) and 20 patients had mixed adenoneuroendocrine carcinoma (MANEC). The median survival was not achieved for both NET G1 and NET G2 versus 19 months (range 3-48) for NEC G3 and 10.5 months (range 3-45) for MANEC. The 3-year survival rates for stage I, II, III, and IV were 91.1 %, 78.6 %, 51.1 % and 11.8 %, respectively (P < 0.001). As for the prognostic analysis, both surgical margin and the newly updated World Health Organization (WHO) classification were independent predictors of overall survival (OS). CONCLUSIONS: G-NENs are a kind of rare tumors, and patients with NET G3 and MANEC have unfavorable prognosis even surgically treated. Moreover, surgical margin and the new 2010 WHO criteria are closely associated with OS for G-NENs.

Clinical selection criteria can predict futile intervention in patients referred for percutaneous endoscopic gastrostomy insertion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) placement is performed in a patient group with high mortality in the short and medium term. For a significant proportion of patients, the procedure provides no increase in survival. There are no standardised assessment tools available to determine the clinical appropriateness of PEG placement, nor any to predict clinical outcome. AIM: The study aims to determine whether clinical assessment, by a trained dietitian, of the appropriateness of PEG placement is predictive of mortality in the short and medium terms. METHODS: A prospective audit was undertaken of all requests for PEG placement at a single large, publicly funded Australian tertiary hospital. The clinical appropriateness of each request was assessed by a trained dietitian, and data on age, sex, reason for referral, comorbidities and satisfaction of assessment criteria were collected, and patient outcome and survival were compared for all patients according to whether a PEG was inserted or not. Main outcome measures were mortality at 30 and 150 days after referral. RESULTS: During the period 2005-2008, 198 patients were referred for PEG; 94 were assessed as appropriate referrals, 104 as inappropriate. Eighty-four patients who underwent gastrostomy, after being assessed as appropriate, had significantly reduced mortality at 30 days (96.4% vs 74.6%, P < 0.0001) and 150 days (82.1% vs 57.9%, P = 0.0001) compared with all other patients. Patients who received PEG despite contrary advice had no significant survival advantage, at 30 days or 150 days, over patients who did not receive PEG. CONCLUSION: The application of selection criteria by trained assessors improves patient selection for PEG insertion and predicts mortality at early and later time points, by identifying patients unlikely to benefit from PEG. The group of patients who received a gastrostomy despite an adverse assessment had no mortality benefit - in these patients, the procedure may have been futile.

Second-look endoscopy after endoscopic submucosal dissection for gastric neoplasms.

Routine second-look endoscopy after gastric endoscopic submucosal dissection (ESD) remains controversial. The aim of the present study was to systematically evaluate the efficacy of second-look endoscopy for gastric ESD. PubMed, the Cochrane library, and the Igaku-chuo-zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data were combined to calculate a pooled odds ratio (OR) for developing post-ESD bleeding. The database search yielded three randomized trials (854 patients). Compared with second-look endoscopy, the pooled OR for post-ESD bleeding without second-look endoscopy was 0.69 (95% confidence interval [CI]: 0.38-1.26, P = 0.228), without significant heterogeneity. There were no significant differences between second-look endoscopy and no second-look endoscopy with regard to large tumor size (>20 mm). This systematic review and meta-analysis showed that second-look endoscopy had no advantage for the prevention of post-ESD bleeding in patients without a high risk of bleeding.

Endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy.

BACKGROUND: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) after surgical gastrectomy is a technically difficult procedure because of the limited working space in the remnant stomach as well as the presence of severe gastric fibrosis and staples under the suture line. OBJECTIVE: We evaluated clinical results including long-term outcomes to determine the feasibility and effectiveness of ESD for EGC in the remnant stomach of patients after gastrectomy. DESIGN: Retrospective study. SETTING: National Cancer Center Hospital, Tokyo, Japan. PATIENTS: We investigated patients undergoing ESD for EGC in the remnant stomach from 1997 to 2011. INTERVENTION ESD MAIN OUTCOME MEASUREMENTS: We examined the patient characteristics, endoscopic findings, technical results, adverse events, and histopathologic results including curability and evaluations of Helicobacter pylori gastritis in addition to the rates of local recurrence, metachronous gastric cancer, overall survival, and cause-specific survival. RESULTS: A total of 128 consecutive patients with 139 lesions had previously undergone 87 distal (68%), 25 proximal (19.5%) and 16 pylorus-preserving gastrectomies (12.5%). The median period from the original gastrectomy to the subsequent ESD for EGC in the remnant stomach was 5.7 years (range 0.6-51 years), the median tumor size was 13 mm (range 1-60 mm), and the median procedure time was 60 minutes (range 15-310 minutes). There were 131 en bloc resections (94%), with curative resections achieved for 109 lesions (78%); 22 lesions (16%) resulted in non-curative resections, and 8 lesions (6%) had only a horizontal margin positive or had inconclusive results. A total of 118 patients (92%) were assessed as H pylori gastritis-positive, with 7 patients (5%) negative. Adverse events included 2 cases of delayed bleeding (1.4%) and 2 perforations (1.4%), with 1 patient requiring emergency surgery. The 5-year overall and cause-specific survival rates were 87.3% and 100%, respectively, during a median follow-up period of 4.5 years (range 0-13.7 years), with no deaths from EGC in the remnant stomach. LIMITATIONS: Single-center, retrospective study. CONCLUSION: ESD for EGC in the remnant stomach of patients after gastrectomy was a feasible and effective therapeutic method and should become the standard treatment in such cases, based on the favorable long-term outcomes.

Is endoscopic resection an acceptable treatment for undifferentiated EGC?

BACKGROUND/AIMS: Endoscopic resection (ER) is an effective treatment in selected patients with early gastric cancer (EGC). We have evaluated the clinical outcomes of ER in patients with undifferentiated EGCs, including poorly differentiated adenocarcinoma or signet ring cell carcinoma. METHODOLOGY: We retrospectively examined the medical records of 77 patients diagnosed with undifferentiated EGC after ER (EMR for 22 patients and ESD for 56 patients) at a single center. RESULTS: The mean±SD lesion size was 23.2±14.1mm. The 77 lesions included 65 (84.4%) intramucosal cancers and 12 (15.6%) involving the submucosal layer. Of these 77 patients, 35 underwent curative resection and 42 did not. After a mean follow-up period of 41 months (range, 9-152), local recurrences were observed in four patients (5.2%), all of whom had not undergone curative resection. No patient died of EGC. Univariate analysis showed that tumor involvement of the resection margins (p<0.001) and lymphatic invasion (p=0.003) were significant risk factors for recurrence after ER in undifferentiated EGCs. However, multivariate analysis did not show any significant risk factors. CONCLUSIONS: ER may be an alternative treatment modality for selected patients with undifferentiated EGCs.

Risk factors and complications following percutaneous endoscopic gastrostomy: a case series of 1041 patients.

BACKGROUND: Most studies exclude patients with severe coagulation disorders or those taking anticoagulants when evaluating the outcomes of percutaneous endoscopic gastrostomy (PEG). OBJECTIVE: To investigate complications and risk factors of PEG in a large clinical series including patients undergoing antiplatelet and anticoagulant therapy. METHODS: During a six-year period, 1057 patients referred for PEG placement were prospectively audited for clinical outcome. Exclusion criteria and follow-up care were defined. Complications were defined as minor or severe. Uni- and multivariate analyses were used to evaluate 14 risk factors. No standardized antibiotic prophylaxis was given. RESULTS: A total of 1041 patients (66% male, 34% female) with the following conditions underwent PEG: neurogenic dysphagia (n=450), cancer (n=385) and others (n=206). No anticoagulants were administered to 351 patients, thrombosis prophylaxis was given to 348 while full therapeutic anticoagulation was received by 313. No increased bleeding risk was associated with patients who had above-normal international normalized ratio values (OR 0.79 [95% CI 0.08 to 7.64]; P=1.00). The total infection rate was 20.5% in patients with malignant disease, and 5.5% in those with nonmalignant disease. Severe complications occurred in 19 patients (bleeding 0.5%, peritonitis 1.3%). Cirrhosis (OR 2.91 [95% CI 1.31 to 6.54]; P=0.008), cancer (OR 2.34 [95% CI 1.33 to 4.12]; P=0.003) and radiation therapy (OR 2.34 [95% CI 1.35 to 4.05]; P=0.002) were significant predictors of post-PEG infection. The 30-day mortality rate was 5.8%. There were no procedure-related deaths. CONCLUSIONS: Cancer, cirrhosis and radiation therapy were predictors of infection. Post-PEG bleeding and other complications were rare events. Collectively, the data suggested that patients taking concurrent anticoagulants had no elevated risk of post-PEG bleeding.

Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria.

BACKGROUND: Criteria for endoscopic resection in patients with early gastric cancer (EGC) have been expanded recently by the National Cancer Centre (NCC). This study compared long-term outcomes in patients with EGC who underwent endoscopic treatment according to guideline criteria with those treated according to expanded criteria. METHODS: Baseline and outcome data from patients undergoing curative endoscopic resection for EGC between January 1999 and December 2005 were collected from electronic medical records. Survival time hazard ratios and 95 per cent confidence intervals were calculated using the Cox proportional hazards model. RESULTS: Of 1485 patients who had a curative resection, 635 (42.8 per cent) underwent resection according to traditional criteria and 625 (42.1 per cent) according to expanded criteria. There was no significant difference in overall survival between the groups. CONCLUSION: Patients who have treatment following the expanded criteria have similar long-term survival and outcomes to those treated according to guideline criteria.

Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement can improve the nutritional status and the ability of a patient with cirrhosis to recover from surgery such as orthotopic liver transplantation. However, cirrhosis has been considered a significant contraindication to PEG tube placement. OBJECTIVE: Our aim in this study was to describe the mortality and complications in a series of cirrhotic patients who underwent PEG at our institution. DESIGN: Retrospective, single-institution case series. PATIENTS: This study involved 26 consecutive patients with cirrhosis who underwent PEG between 1995 and 2005. INTERVENTION: PEG tube placement. MAIN OUTCOME MEASUREMENTS AND RESULTS: The 30-day mortality of the series of patients was 10 of 26 (38.5%), whereas the 90-day mortality was 11 of 26 (42.3%). Nine of the 10 patients who died in the first 30 days had ascites at the time of PEG tube placement. Two patients died as a direct consequence of complications from the PEG procedure, whereas the other deaths were related to progression of liver disease or factors not directly related to the PEG. LIMITATIONS: The patients in this case series had varying levels of illness and reasons for PEG tube placement such that a generalization of outcomes may not be possible. CONCLUSIONS: The overall mortality of patients with cirrhosis who underwent PEG is high. Although there is an increased risk, PEG tube placement in cirrhotic patients without ascites may be less risky. The benefits of PEG tube placement in patients with cirrhosis should be weighed heavily against the risks.

Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer.

BACKGROUND/AIM: Laparoscopy-assisted surgery has proved useful in the treatment of early gastric cancer, but its use in advanced cancer has rarely been studied. To investigate the efficacy and advantages of laparoscopy-assisted distal gastrectomy (LADG) with D2 dissection of lymph nodes versus conventional open D2 distal gastrectomy (ODG) in advanced gastric cancer. METHODS: From January 2007 to June 2008, the clinical data of 66 cases of LADG for advanced gastric cancer were compared with that of 69 patients who, during the same period, underwent a conventional open radical distal gastrectomy. RESULTS: No patient in the LADG group converted to conventional operation with laparotomy. Operative time was significantly longer for the LADG group than for the ODG group (266.05 +/- 55.05 vs. 223.78 +/- 26.79 min). No significant differences were found in the total number of retrieved lymph nodes (25.81 +/- 12.53 vs. 27.47 +/- 10.28) between the two groups. Patients in the LADG group had less blood loss, shorter time of analgesic use, earlier recovery of bowel activity, and shorter postoperative hospitalization time. Complication rates were comparable between the two groups. CONCLUSIONS: LADG with D2 lymph node dissection is a safe and feasible procedure with adequate lymphadenectomy for the treatment of advanced gastric cancer. A large-scale prospective randomized trial with a longer follow-up period is needed to definitively assess whether LADG is a better alternative than ODG with D2 lymph node dissection.

[Risk factors of early mortality after percutaneous endoscopic gastrostomy: a retrospective study].

When performing percutaneous endoscopic gastrostomy (PEG), the associated risks must always be kept in mind. We investigated and analyzed early mortality after PEG, retrospectively. Of the 302 patients (63% males, mean age 75 years) who underwent PEG at our center from 1999 to 2008, 7 patients (2.3%) were dead within 30 days of the procedure. Only one death could be directly related to the procedure. By a logistic regression analysis, the following 3 factors were identified as independent preoperative risk factors for death within 30 days of the PEG: (1) high serum creatinine level [mg/dl, p=0.006, odds ratio (OR)=8.472]; (2) past history of ischemic heart disease [p=0.008, OR=9.985]; (3) low serum albumin level [g/dl, p=0.017, OR=0.096]. In patients with poor renal function, poor cardiac function, severe malnutrition or exhaustion, the indications for PEG need to be very carefully investigated.

A comparative study on endoscopic submucosal dissection and laparoscopy-assisted radical gastrectomy in the treatment of early gastric carcinoma.

PURPOSE: To compare the clinical efficacy and safety of endoscopic submucosal dissection (ESD) and laparoscopy-assisted radical gastrectomy (LARG) in the treatment of early gastric carcinoma (EGC) with different risks of lymph node metastasis. METHODS: The clinical data of 194 EGC patients who underwent ESD (ESD group, n=58) or LARG (LARG group, n=136) in our hospital from January 2014 to January 2016 were collected. The baseline data, pathological features of tumor, perioperative indexes and long- and short-term complications were compared between the two groups, the overall survival (OS) rate of patients was recorded through follow-up, and the tumor-free survival (TFS) rate was compared after ESD and LARG for EGC with different risks of lymph node metastasis. RESULTS: The general clinical features were comparable between the two groups of patients, and there was no perioperative death. The pathological features of the tumor had no statistically significant differences between the two groups (p>0.05). The operation time in ESD group (73.57±21.30 min) was significantly shorter than that in LARG group (159.22±39.40 min) (p<0.001), and the time of first ambulation after operation in ESD group (1.6±0.8 d) was also overtly shorter than that in LARG group (3.5±1.7 d) (p<0.001). Postoperatively, no drainage tube was placed in the ESD group, while it was placed for 5.7±2.4 days on average in the LARG group. The time of first flatus after operation, time of first liquid diet after operation, and total hospitalization time in the ESD group were significantly compared with the LARG group (p<0.001). The incidence rate of short-term complications after surgery was 10.3% and 7.4% in the two groups, (p=0.570), while long-term complications were 17.6% (9/51) and 20.9% (24/115) in the two groups (p=0.631). The in situ tumor recurrence by the end of follow-up was 3.92% (2/51) and 0.87% (1/115) in the two groups, while the ectopic recurrence rate was 5.89% (3/51) and 0.87% (1/115) (p=0.173, p=0.087). OS survival was 96.1% (49/51) and 97.4% (112/115) in the two groups (p=0.751). The postoperative TFS of EGC patients with a low risk of lymph node metastasis was 93.8% (30/32) and 98.6% (70/71) in the two groups, again without significant difference (p=0.197). The postoperative TFS of EGC patients with a high risk of lymph node metastasis was 84.2% (16/19) and 97.7% (43/44) in the two groups, with statistically significant difference (log-rank, p=0.034). CONCLUSIONS: ESD is characterized by small trauma, rapid postoperative recovery, postoperative recurrence and survival comparable to those after surgical operation and high safety for EGC with a low risk of lymph node metastasis. LARG can reduce the postoperative recurrence rate of EGC in patients with high risk of lymph node metastasis.