An advanced bipolar device helps reduce the rate of postoperative pancreatic fistula in laparoscopic gastrectomy for gastric cancer patients: a propensity score-matched analysis.

BACKGROUND: Advanced bipolar devices (ABD; e.g., LigaSure™) have a lower blade temperature than ultrasonically activated devices (USAD; e.g., Harmonic® and Sonicision™) during activation, potentially enabling accurate lymph node dissection with less risk of postoperative pancreatic fistula (POPF) due to pancreatic thermal injury in laparoscopic gastrectomy. Therefore, we compared the efficacy and safety of ABD and USAD in laparoscopic gastrectomy for gastric cancer patients. METHODS: A retrospective cohort study was conducted on patients who underwent laparoscopic distal gastrectomy (LDG) between August 2008 and September 2020. A total of 371 patients were enrolled, and short-term surgical outcomes, including the incidence of ISGPF grades B and C POPF, were compared between ABD and USAD. The risk factors for POPF in LDG were investigated by univariate and multivariate analyses. RESULTS: A propensity score-matching algorithm was used to select 120 patients for each group. The POPF rate was significantly lower (0.8 vs. 9.2%, p < 0.001), the morbidity rate was lower (13.3 vs. 28.3%, p < 0.001), the length of postoperative hospitalization was shorter (14 vs. 19 days, p < 0.001), and the lymph node retrieval rate was higher (34 vs. 26, p < 0.001) with an ABD than with a USAD. There were no mortalities in either group. A multivariate analysis showed that a USAD was the only independent risk factor with a considerably high odds ratio for the occurrence of POPF (USAD/ABD, odds ratio 8.38, p = 0.0466). CONCLUSION: An ABD may improve the safety of laparoscopic gastrectomy for gastric cancer patients.

A phase II study of ramelteon for the prevention of postoperative delirium in elderly patients undergoing gastrectomy.

PURPOSE: The growing number of cases of gastric cancer being diagnosed in elderly patients highlights the importance of preventing postoperative delirium. This phase II study aimed to evaluate the efficacy of perioperative treatment with ramelteon for preventing postoperative delirium in elderly patients undergoing gastrectomy. METHODS: This study was designed as a single-institute prospective phase II study. Patients ≥ 75 years old were eligible. Ramelteon 8 mg/day was administered from 8 days before the operation until discharge. Postoperative delirium was evaluated using the Confusion Assessment Method-Intensive Care Unit flow sheet. RESULTS: Between September 2015 and July 2017, a total of 83 patients were enrolled, 76 of whom were eligible and included in the analysis. Postoperative delirium was observed in four patients (5%) (60% confidence interval: 3.0-8.7). The upper margin of the confidence interval was lower than the prespecified threshold of 13%; therefore, the null hypothesis was rejected. CONCLUSION: This phase II study suggested that the perioperative administration of ramelteon is safe and feasible for preventing postoperative delirium in elderly patients undergoing gastrectomy. Trial registration This study was registered at UMIN (UMIN 000018697).

Risk Factors for Postoperative Delirium After Gastrectomy in Gastric Cancer Patients.

PURPOSE: The incidence of postoperative delirium is reported to range from 9 to 87%; however, no report has focused on cases of postoperative delirium in gastric cancer surgery alone. Therefore, we investigated the incidence of and risk factors for postoperative delirium after gastrectomy in patients with gastric cancer. METHODS: A total of 1037 patients who underwent surgery were included in the study. Patients were divided into two groups-those with (delirium group) or without (non-delirium group) postoperative delirium-and their backgrounds were compared. The short-term outcomes and the overall survival were also investigated. RESULTS: Postoperative delirium was observed in 47 of 1037 patients (4.5%). A multivariate analysis revealed that male gender, age ≥ 75 years, a history of cerebrovascular disease, and the habitual use of sleeping pills were independent predictive factors for postoperative delirium. The postoperative hospital stay was significantly longer in the postoperative delirium group than in the non-delirium group. Postoperative delirium was significantly associated with postoperative complications. The 3-year overall survival was 74.3% in the delirium group and 85.5% in the non-delirium group (log-rank p = 0.006). A multivariate analysis revealed that postoperative delirium was an independent prognostic factor, along with the age and cancer stage. CONCLUSION: The incidence of postoperative delirium was 4.5% in gastric cancer patients. Male gender, age ≥ 75 years, a history of cerebrovascular disease, and the habitual use of narcoleptic agents were risk factors for postoperative delirium after gastrectomy in gastric cancer patients. Postoperative delirium was strongly associated with other postoperative complications and a poor survival after surgery.

Prospective phase II study evaluating the efficacy of swallow ability screening tests and pneumonia prevention using a team approach for elderly patients with gastric cancer.

BACKGROUND: Aging partly impairs swallowing function, which is considered a risk factor for postoperative pneumonia (PP). We evaluated the efficacy of a new team-based strategy to reduce the incidence of PP in elderly patients with gastric cancer. METHODS: This single-center, prospective phase II study included elderly patients (≥75 years old) with gastric cancer undergoing gastric surgery. The primary endpoint was the incidence of Clavien-Dindo grade II or higher PP. Patients were initially screened using three swallowing function screening tests: a symptom questionnaire, the modified water swallow test (MSWT), and the repetitive saliva swallowing test (RSST). All patients were provided standard preoperative oral checks and care and simple neck muscle training. For patients who screened positive, a videofluorographic swallowing study was performed; if an abnormality was found, the patient was given intensive swallowing rehabilitation both pre- and postoperatively. RESULTS: Of 86 eligible patients enrolled, PP developed in 3 (3.5%). The 60% confidence interval of 1.8-6.3% had an upper limit below the prespecified threshold of 7.8%. Positive screening results were found for 19 patients (22.1%) on the symptom questionnaire, 3 (3.5%) on the MSWT, and 1 (1.2%) on the RSST. PP was not observed in any patients who screened positive. CONCLUSION: In conclusion, although the screening tests we adopted here were not sufficient to identify patients at high risk of aspiration pneumonia, perioperative interventions using a team approach might be effective in reducing the incidence of PP in elderly patients with gastric cancer.

A case of multicentric pancreatic mixed acinar-ductal carcinoma diagnosed by a yogurt-like cell clump flowing from the papilla of Vater.

BACKGROUND: Histological confirmation is needed when the pancreatic lesions is uncertain for neoplastic or nonneoplastic. Current case with multicentric pancreatic carcinomas showing indefinite clinical images was successfully diagnosed by a biopsy of a novel object expelled from the papilla. CASE PRESENTATION: A 71-year-old male was referred because of elevated serum pancreatic enzymes. Computed tomography revealed an unclear low-density area in the pancreatic body without evidence of tumor and mild dilation of the upstream main pancreatic duct (MPD). Other images, including abdominal ultrasound, endoscopic ultrasound, and magnetic resonance imaging, did not demonstrate cancerous findings. Endoscopic retrograde cholangiopancreatography showed a crab-claw-like obstruction in the MPD. Surprisingly, the component constituting the obstruction was moved by contrast injection and spilled out of the papilla orifice as a yogurt-like white object. Biopsy of this object by histology revealed a cancer cell clump. Pancreatectomy was performed, and pathology of the resected pancreas showed multiple nodular tumors replacing the acini and extending into the MPD. These neoplasms histologically resembled mixed acinar-ductal carcinoma. CONCLUSION: Current report presented a rare tumor with multicentric pancreatic lesions, preoperatively diagnosed by a biopsy of an uncommon substance.

Effects of initial disease status on lymph flow following gastrectomy in cases of carcinoma in the remnant stomach.

PURPOSE: In cases of carcinoma in the remnant stomach (CRS), the lymphatic flow may be altered by the initial surgery. In this study of CRS after gastrectomy, we investigated how the regions of lymph node metastasis and changes in lymphatic flow depend on initial disease status. METHOD: The study included 76 patients with CRS who underwent gastrectomy between September 2002 and November 2014. We analyzed and compared the clinicopathological factors and survival periods between patients after distal gastrectomy for malignant disease (group M, 33 patients) and patients after distal gastrectomy for benign disease (group B, 43 patients). RESULTS: The depth of tumor invasion was more advanced in group B (T1/T2/T3/T4: group M 18/1/7/7, group B 8/11/8/16; P = 0.002). However, the degree of lymph node metastasis did not differ significantly between the two groups. The incidence of lymph node metastasis was high at stations 2 (19 %), 4sa (17 %), 10 (25 %), 11p (19 %), and 11d (27 %) in group M and 1 (14 %), 3 (23 %), and 4sb (15 %), and the mesojejunal lymph node (21 %) in group B. Lymph node dissection was highly beneficial at station 3, station 7, and the mesojejunum in both groups, but not at stations 10 or 11d. CONCLUSION: As compared with group B, group M showed higher incidences of lymph node metastasis in the greater curvature, splenic hilum, and lymph nodes along the splenic artery, suggesting the predominance of lymphatic flows from the greater curvature to the splenic hilum and from the remnant stomach to the splenic artery.

Robotic surgery for gastric cancer.

Laparoscopic gastrectomy is a widely used minimally invasive surgery for gastric cancer. However, skillful techniques are required to perform lymph node dissection using straight shaped forceps, particularly for D2 dissection. Robotic surgery using the da Vinci surgical system is anticipated to be a powerful tool for performing difficult techniques using high-resolution three-dimensional (3D) images and the EndoWrist equipped with seven degrees of freedom. Attempts are being made to apply robotic surgery in gastrectomy procedures mainly in Japan, South Korea, and Europe. Although definite superiority to laparoscopic gastrectomy is yet to be proven, robotic surgery has been reported to have a shorter learning curve and offer more precise dissection for total gastrectomy. Hence, its oncological efficacy needs to be verified in a clinical trial.

[A case of pathological complete response after treatment with uracil/tegafur (UFT) and folinate (Leucovorin) for liver metastasis of colon cancer].

The patient is a 62-year-old female who underwent a right hemicolectomy for type-2 ascending colon cancer (moderately-differentiated adenocarcinoma, ss, n0, H0, P0, M0, stage II). Six months after the surgery, a solitary metastatic focus was expressed in the liver S3. Because schizophrenia was present concurrently, tegafur and uracil/folinate (UFT/Leucovorin) treatment was selected and performed for 3 months. Because the tumor shrank afterward, a partial hepatectomy was performed to obtain a curative resection. In a pathological examination of the resected focus, cicatricial/necrotic findings were observed, but no cancer cells were observed; hence, it was determined to be a pathological complete response (CR). In regard to chemotherapy for distant metastasis of colorectal cancer, many molecular-targeted agents are being introduced, thus resulting in more treatment options; however, depending on the patient's background, UFT/LV treatment can be an effective treatment option.