Safe and Accurate Laparoscopic Total Gastrectomy for Remnant Gastric Cancer With Severe Adhesions Using Indocyanine Green Fluorescence Imaging: Guidance in Detection of the Accurate Dissection Layer to Avoid Organ Injury.

Laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) requires advanced techniques due to severe postoperative adhesions and anatomic changes. We performed LTG in 2 patients with RGC using intraoperative indocyanine green (ICG) fluorescence imaging. Both cases previously underwent distal gastrectomy with Billroth-I reconstruction for gastric cancer and were subsequently diagnosed with early-stage gastric cancer of the remnant stomach. Indocyanine green (2.5 mg/body) was administered intravenously during surgery. The liver and common bile duct were clearly visualized during surgery using near-infrared fluorescence laparoscopy, and the adhesions between the hepatobiliary organs and remnant stomach were safely dissected. Laparoscopic total gastrectomy was successfully performed without complications, and the postoperative course was uneventful in both cases. Intraoperative real-time ICG fluorescence imaging allows clear visualization of the liver and common bile duct and can be useful in LTG for RGC with severe adhesions.

Accuracy of preoperative staging of gastric stump cancer.

BACKGROUND: In this study, the accuracy of preoperative staging for gastric stump cancer, which has not been thoroughly investigated since the condition is rare, was investigated using computed tomography and gastroscopic imaging. METHODS: Between February 1994 and April 2018, 49 patients with gastric stump cancer, following subtotal or total gastrectomy, were reviewed retrospectively. Preoperative diagnoses of clinical T and clinical N categories were compared with post-operative pathological diagnoses (pT and pN categories). Positive predictive values, accuracy, sensitivity and specificity were also evaluated. RESULTS: The overall accuracy of T staging was 40.8%. The positive predictive value for cT3/T4 was 96.3%, whereas the positive predictive value for cT1/T2 was 72.7%. The overall accuracy for N staging was 61.2%. The positive predictive value of lymph node positive patients was 73.3%. The positive predictive value and sensitivity of over stage II were 96.6% and 84.8%, respectively. CONCLUSIONS: The accuracy of preoperative diagnosis using both computed tomography and gastroscopy imaging may be feasible for T3/T4 advanced gastric stump cancer, whereas diagnosing T1/2 gastric stump cancer must be carefully considered due to high misdiagnosis rates, relating to depth.

A comparison of quality of life between patients with small and large gastric remnant volumes after gastrectomy for gastric cancer.

ABSTRACT: The impact of gastric remnant volumes (GRVs) after gastrectomy on patients' quality of life (QOL) has not yet been clarified. The aim of the present study was to compare QOL after gastrectomy between small and large gastric remnant volume patients.We prospectively collected clinical data from 78 consecutive patients who underwent distal gastrectomy with Billroth II gastrojejunostomy for gastric cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach questionnaire and gastric computed tomography scans were performed. The patients were subdivided into 2 groups by remnant stomach volume (the S group ≤110 mL vs L group >110 mL).The worst scores for most items were observed at postoperative month 1 and usually improved thereafter. There was no difference in the STO22 score except for dysphagia between the S and L groups after gastrectomy (P > .05). The QOL score of dysphagia was different at postoperative 6 months (S vs L, 12.4 vs 22.8, P < .03), but there was no difference at postoperative months 1, 3, 12, 24, or 36 (P > .05).The remnant gastric volume after partial gastrectomy affects neither functional differences nor QOL after 6 months following appropriate radical surgery.

Correlation of weight loss with residual gastric volume on computerized tomography in patients undergoing sleeve gastrectomy: A systematic review.

Laparoscopic Sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure worldwide. There is wide variation however in post-operative weight loss on long term follow-up, and residual gastric volume (RGV) is believed to be an important variable. Multiple studies have correlated RGV as assessed by Computerized Tomography volumetry with excess weight loss (EWL%) following LSG, but definite consensus is lacking. This article systematically reviews the published studies in English literature to ascertain whether any correlation exists between the RGV and EWL% following LSG. Ten studies were included in this review, and significant differences were noted in the technique of RGV assessment, and timing of RGV and EWL% assessment. Five studies found a statistically significant correlation between the RGV and EWL%. One study found a correlation which did not reach statistical significance. Two additional studies reported that the resected volume rather than RGV correlated with the EWL%. Meta-analysis of studies reporting correlation between RGV and EWL% showed that up to 26.3% (95% CI: 5.1%-56.1%) of variability in EWL% can be explained by variations in RGV. A lower RGV is likely to result in a better post-operative weight loss following LSG. There is need for standardization of technique and timing of RGV assessment.

Gastric Remnant Perforation Caused by Peterson's Hernia Following One Anastomosis Gastric Bypass: a Rare Complication.

INTRODUCTION: One anastomosis gastric bypass (OAGB) has gained popularity over the recent years; it appears to be an effective bariatric procedure with acceptable weight loss, co-morbidity resolution, and complication rates in the short and medium term. However, it still continues to have concerns in the bariatric community due to a spectrum of potential complications. To our knowledge, there are few published cases of internal hernia, but no published reports of gastric remnant perforation following OAGB. CASE PRESENTATION: We report a case of a 32-year-old female who developed a perforation of the remnant stomach along the gastric fundus secondary to bowel obstruction 5 years after OAGB. The perforation was managed by stapled resection of the perforated fundus and closure of Peterson's space for potential hernia as a causative factor, and the patient had a smooth postoperative recovery. DISCUSSION: Early diagnosis is crucial in post bariatric emergencies with a low threshold of early intervention. Gastric remnant perforation was previously described in some reports following Roux-en-Y gastric bypass (RYGB) but not after OAGB. Etiology of perforation can be rationalized to primary gastric remnant pathology or secondary to external factors such as back pressure of mechanical/functional bowel obstruction. CONCLUSION: Peterson's hernia and gastric remnant perforation are rare, yet serious, complications that need to be kept in mind while dealing with post-OAGB patients presenting with abdominal pain. Early diagnosis and treatment are essential for a better outcome.

Bile Reflux is a Common Finding in the Gastric Pouch After One Anastomosis Gastric Bypass.

INTRODUCTION: Data on postoperative bile reflux after one anastomosis gastric bypass (OAGB) is lacking. Bile reflux scintigraphy (BRS) has been shown to be a reliable non-invasive tool to assess bile reflux after OAGB. We set out to study bile reflux after OAGB with BRS and endoscopy in a prospective series (RYSA Trial). METHODS: Forty patients (29 women) underwent OAGB between November 2016 and December 2018. Symptoms were reported and upper gastrointestinal endoscopy (UGE) was done preoperatively. Six months after OAGB, bile reflux was assessed in UGE findings and as tracer activity found in gastric tube and esophagus in BRS (follow-up rate 95%). RESULTS: Twenty-six patients (68.4%) had no bile reflux in BRS. Twelve patients (31.6%) had bile reflux in the gastric pouch in BRS and one of them (2.6%) had bile reflux also in the esophagus 6 months postoperatively. Mean bile reflux activity in the gastric pouch was 5.2% (1-21%) of total activity. De novo findings suggestive of bile reflux (esophagitis, stomal ulcer, foveolar inflammation of gastric pouch) were found for 15 patients (39.5%) in postoperative UGE. BRS and UGE findings were significantly associated (P = 0.022). Eight patients experienced de novo reflux symptoms at 6 months, that were significantly associated with BRS and de novo UGE findings postoperatively (P = 0.033 and 0.0005, respectively). CONCLUSION: Postoperative bile reflux in the gastric pouch after OAGB is a common finding in scintigraphy and endoscopy. The long-term effects of bile exposure will be analyzed in future reports after a longer follow-up. TRIAL REGISTRATION: Clinical Trials Identifier NCT02882685.

The investigation of diet recovery after distal gastrectomy.

This study aims to investigate the adaptation process of the alimentary tract after distal gastrectomy and understand the impact of remnant stomach volume (RSV) on diet recovery.One year after gastrectomy, although patients' oral intake had increased, the RSV was decreased and small bowel motility was enhanced. Patients with a larger RSV showed no additional benefits regarding nutritional outcomes.We prospectively enrolled patients who underwent distal gastrectomy with Billroth II reconstruction to treat gastric cancer at a tertiary hospital cancer center between September 2009 and February 2012. Demographic data, diet questionnaires, computed tomography (CT), and contrast fluoroscopy findings were collected. Patients were divided into 2 groups according to the RSV calculated using CT gastric volume measurements (large vs small). Dietary habits and nutritional status were compared between the groups.Seventy-eight patients were enrolled. Diet volume recovered to 90% of baseline by the 36 postoperative month, and RSV was 70% of baseline at 6 months after surgery and gradually decreased over time. One year after surgery, small bowel transit time was 75% compared to the 1st postoperative month (P < .05); however, transit time in the esophagus and remnant stomach showed no change in any studied interval. Compared to patients with a small RSV, those with a large RSV showed no differences in diet volume, habits, or other nutritional benefits (P > .05).Diet recovery for distal gastrectomy patients was achieved by increased small bowel motility. The size of the remnant stomach showed no positive impact on nutritional outcomes.

Material de sutura quirúrgica: una expectoración inusual / Surgical suture material: an unusual expectoration

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A new diagnostic method using air perfusion radiography under DSA for gastric stump-pleural fistula: Report of five cases.

Gastric stump-pleural fistula is a common complication following gastroesophageal anastomosis in patients diagnosed with gastric cancer. Mortality is high because of the severe subsequent relevant complications caused by the fistula. Here we report five cases of gastric stump-pleural fistula diagnosed by air perfusion radiography under digital subtraction angiography (DSA). DSA air perfusion radiography provides a reliable basis for the development of clinical programmes; it is a simple method which does not involve any pain or trauma to the patient.

Gastric remnant perforation in a gastric bypass patient secondary to splenic artery pseudoaneurysm: radiologic-surgical correlation.

One of the more common effective surgical procedures performed today for obesity is the Roux-en-Y gastric bypass. Though effective, both early and late complications do occur. Gastric remnant hemorrhage after gastric bypass is an uncommon late complication, posing both diagnostic and therapeutic difficulties. We report a case of gastrointestinal bleed and gastric remnant rupture secondary to splenic artery pseudoaneurysm 14 years after initial bariatric surgery. Given altered surgical anatomy in gastric bypass procedures, diagnosis and treatment of the source of a gastrointestinal bleed in a Roux-en-Y gastric bypass patient may require a multimodality and multidisciplinary approach.

Imaging after Bariatric Surgery: When Interpretation Is a Challenge, from Normal to Abnormal.

Bariatric surgery has proven to be the most effective weight loss strategy in severe obesity. Imaging in the immediate postoperative period of bariatric surgery is not done routinely. However, it is helpful in the assessment of early and late complications, which are estimated to be present in < 1% of patients. In some cases, the imaging interpretation of anatomical outcomes and complications related to these procedures represents a challenge for surgeons and radiologists. The aim of this review is to describe the imagenologic findings after bariatric surgery and focuses on the findings of the most frequent procedures performed in Colombia such as laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Contrasted CT scan and fluoroscopic studies have shown a high sensitivity in the early and late diagnosis of bariatric surgery complications, but in order to be able to appropriately identify these complications, it is important to be familiar with the normal or expected radiological findings.

Cholangitis secondary to afferent loop syndrome from a gastric stump adenocarcinoma.

A clinical case of an 85-year-old patient with cholangitis secondary to afferent loop syndrome from gastric stump adenocarinoma. A brief review of the literature on it is made.

Intussusception After Roux-en-Y Gastric Bypass: Laparoscopic Management.

INTRODUCTION: Intussusception represents an uncommon cause of intestinal obstruction after Rouxen-Y gastric bypass. Symptoms are not specific and clinical presentation may vary from acute intestinal obstruction with or without bowel necrosis to intermittent or chronic pain. CT scan is the diagnostic test of choice. MATERIALS AND METHODS: A 38-year-old woman who had undergone RYGBP 5 months prior was admitted to our Emergency Department with acute abdominal pain, alimentary and bilious vomiting, and fever. A CT scan revealed an intussusception after the anastomosis and dilatation of the biliopancreatic limb and the gastric remnant. An emergency laparoscopic exploration was performed. RESULTS: The patient undergoes an explorative laparoscopy. A bowel intussusception starting distally at the jejunojejunostomy and involving the latter is discovered. The common channel is divided first, and after that, the alimentary limb is resected. The biliary limb is identified, marked, and finally divided. A side-to-side jejunojejunal anastomosis is created between the alimentary limb and the common limb. Finally, the anastomosis between the common limb and the biliopancreatic limb is fashioned about 30 cm distally from the latter anastomosis. The total operative time was 130 min. Postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. CONCLUSION: Although rare, intussusception after RYGBP must be considered as a possible cause of intestinal obstruction. In case of a small bowel intussusception, a surgical resection is recommended. A laparoscopic approach to treat bowel intussusception after RYGBP is safe and feasible.

Colangitis secundaria a síndrome de asa aferente por adenocarcinoma sobre el muñón gástrico / Cholangitis secondary to afferent loop syndrome from a gastric stump adenocarcinoma

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EUS-Guided Endoscopic Gastrointestinal Anastomosis with Lumen-Apposing Metal Stent: Feasibility, Safety, and Efficacy.

Traditionally, restoration of normal bowel continuity after resection and bypass of a diseased or obstructed gastrointestinal tract can only be achieved through surgery, which can be technically challenging and comes with a risk of adverse events. Here, we describe our institutions' experience with endoscopic-guided gastroenterostomy or enteroenterostomy with lumen-apposing metal stent (LAMS) from March 2015 to August 2016. Ten patients had gastrogastrostomy (gastric pouch to gastric remnant) and three patients had jejunogastrostomy (Roux limb to gastric remnant) for the reversal of Roux-en-Y bariatric surgery. One patient had gastroduodenostomy (stomach to duodenal bulb) post antrectomy and one patient had jejunojejunostomy for distal obstruction following Roux-en-Y reconstruction. Technical and clinical success were achieved in all patients, save for delayed anastomotic stenosis following stent removal in one patient, with a mean follow-up of 126 days (3-318 days) with minimal complications in two patients. Endoscopic gastrointestinal anastomosis therefore may be a safe and feasible technique to re-establish continuity of the digestive system following bypass in the short-term.

Neuroendocrine carcinoma of the gastric stump: A case report and literature review.

We herein report a case of neuroendocrine carcinoma of the gastric stump found 47 years after Billroth II gastric resection for a benign gastric ulcer. A 74-year-old man was referred to another hospital with melena. Endoscopic examination revealed a localized ulcerative lesion at the gastrojejunal anastomosis. The diagnosis by endoscopic biopsy was neuroendocrine carcinoma. A total gastrectomy of the remnant stomach with D2 lymphadenectomy was performed at our hospital. The lesion invaded the subserosa, and metastasis was found in two of nine the lymph nodes retrieved. The lesion was positive for synaptophysin and chromogranin A, and the Ki-67 labeling index was 60%. The diagnosis of neuroendocrine carcinoma of the gastric stump was confirmed using World Health Organization 2010 criteria. Subsequently, the patient underwent one course of adjuvant chemotherapy with the etoposide plus cisplatin (EP) regimen; however, treatment was discontinued due to grade 3 myelosuppression. The patient showed lymph node metastasis in the region around the gastrojejunal anastomosis in the abdominal cavity 7 mo post-surgery. He then underwent radiotherapy and platinum-based combination chemotherapy; however, the disease progressed and liver recurrence was observed on follow-up computed tomography at 16 mo post-surgery. The patient then received chemotherapy with regimens used for the treatment of small cell lung cancer in first- and second-line settings. The patient died of disease progression 31 months after surgery.