Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study / Asociación entre el uso de protocolos de recuperación intensificada y complicaciones postoperatorias tras cirugía gástrica por cáncer (POWER 4): estudio nacional, prospective multicéntrico

Introduction: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. Methods: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). Results: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. Conclusions: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. (AU)

Introducción: La efectividad de los protocolos de recuperación intensificada o ERAS en la cirugía del cáncer gástrico sigue siendo controvertida. Métodos: Estudio de cohortes prospectivo multicéntrico de pacientes intervenidos de cáncer gástrico. Se evaluó la adherencia a 22 elementos ERAS en todos los pacientes, independientemente de la existencia de un protocolo ERAS. Cada centro tuvo un período de reclutamiento de tres meses, con un seguimiento de 30 días. La medida de resultado primario fue el numero de complicaciones posoperatorias moderadas a graves. Las medidas de resultado secundarias fueron el número total de complicaciones, la adherencia a los elementos ERAS, la mortalidad y la estancia. Resultados: Se incluyeron 743 pacientes en 72 hospitales, 211 (28,4 %) en centros ERAS. 245 pacientes (33 %) experimentaron complicaciones posoperatorias, moderadas o graves en 172 (23,1 %). No hubo diferencias en la incidencia de complicaciones moderadas a graves (22,3 % vs. 23,5 %; OR, 0,92 (IC 95 %, 0,59 a 1,41); P = 0,068), o complicaciones posoperatorias totales entre los centros ERAS y no ERAS (33,6 % vs. 32,7 %; OR, 1,05 (IC 95 %, 0,70 a 1,56); P = 0,825). La adherencia a los elementos ERAS fue del 52% [IQR 45 a 60]. No hubo diferencias entre los cuartiles de cumplimiento ERAS más alto (Q1, > 60 %) y más bajo (Q4, ≤ 45 %). Conclusiones: Ni la aplicación parcial de medidas ERAS ni el tratamiento en centros ERAS mejoraron los resultados en pacientes sometidos a cirugía gástrica por cáncer. (AU)

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study.

INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.

An unusual finding in gastroesophageal surgery: gastric anthracosis.

We present the case of a patient with an unusual finding of gastric anthracosis during oncological surgery for gastric adenocarcinoma.

Síncope como debut clínico de un vólvulo gástrico agudo / Syncope as the clinical presentation in a case of acute gastric volvulus

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Tratamiento endoscópico no quirúrgico del vólvulo gástrico en pacientes con riesgo quirúrgico extremo / Nonsurgical endoscopic treatment of gastric volvulus in extremely high-risk surgical patients

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Nonsurgical endoscopic treatment of gastric volvulus in extremely high-risk surgical patients.

Gastric volvulus is a rare entity that occurs as a consequence of a rotation of the stomach of more than 180°, with gastric outlet obstruction and vascular compromise. It occurs secondary to diaphragmatic defects in most cases and is mainly reported in elderly patients who are fragile and present severe associated comorbidities. Here we present a nonsurgical treatment with the use of a single percutaneous endoscopic tube to perform gastropexy in patients with a high risk for surgery or inoperable patients. We present two cases that show that this therapeutic option is viable, with acceptable results under very specific clinical conditions.

Anastomosis gastroyeyunal con separación gástrica parcial frente al tratamiento endoscópico para el tratamiento del síndrome de obstrucción antroduodenal de causa maligna / Stomach-partitioning gastrojejunostomy versus stent placement for the treatment of malignant gastric outlet obstruction

Introducción: El síndrome de obstrucción antroduodenal es una complicación presente en neoplasias avanzadas. Se caracteriza por clínica de obstrucción gastrointestinal alta, con desnutrición progresiva, y se asocia con una disminución de la supervivencia. La derivación mediante gastroyeyunostomía y el tratamiento endoscópico (TE) son las alternativas para el tratamiento del síndrome de obstrucción antroduodenal. El objetivo de este estudio es comparar la eficacia y la supervivencia de ambas. Métodos: Estudio monocentro, observacional y prospectivo de 58 pacientes con síndrome de obstrucción antroduodenal que recibieron tratamiento quirúrgico mediante gastroyeyunostomía con separación gástrica parcial (GYSGP) o TE con prótesis enterales autoexpandibles entre los años 2007-2018. Resultados: A 30 pacientes se les realizó GYSGP y a 28 pacientes TE. La edad media de los pacientes con GYSGP fue significativamente menor (69 vs. 78 años, p = 0,001). No hubo diferencias en cuanto al sexo, el riesgo anestésico-quirúrgico ni la etiología de la neoplasia. Las complicaciones posprocedimiento fueron superiores, aunque no significativas, en el grupo de GYSGP (p = 0,156). El TE se asoció con una menor estancia hospitalaria (p = 0,02) y una mayor precocidad de la tolerancia oral (p < 0,0001). Sin embargo, los pacientes presentaron tasas más altas de obstrucción persistente y recurrente (p = 0,048 y 0,01, respectivamente), unos peores objetivos energéticos (p = 0,009) y una supervivencia menor (9,61 vs. 4,47 meses, p = 0,008). Conclusiones: La GYSGP obtiene una mayor permeabilidad luminal, una mejor tolerancia a la vía oral y una mayor supervivencia. El TE estaría recomendado para pacientes no subsidiarios de la cirugía con un pronóstico limitado a corto plazo

Introduction: Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques. Methods: Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018. Results: Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P = .001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P = .156). SP was associated with a shorter hospital stay (P = .02) and faster oral intake (P < .0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P = .048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P = .008). Conclusions: SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis

Stomach-partitioning gastrojejunostomy versus stent placement for the treatment of malignant gastric outlet obstruction. / Anastomosis gastroyeyunal con separación gástrica parcial frente al tratamiento endoscópico para el tratamiento del síndrome de obstrucción antroduodenal de causa maligna.

INTRODUCTION: Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques. METHODS: Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018. RESULTS: Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P=.001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P=.156). SP was associated with a shorter hospital stay (P=.02) and faster oral intake (P<.0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P=.048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P=.008). CONCLUSIONS: SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis.

[Partial stomach partitioning gastrojejunostomy in the treatment of the malignant gastric outlet obstruction]. / Gastro yeyuno anastomosis con separación gástrica parcial en el tratamiento de la obstrucción gastroduodenal secundaria a cáncer gástrico avanzado.

BACKGROUND: In patients with unresectable gastric cancer and outlet obstruction syndrome, gastric partitioning gastrojejunostomy is an alternative, which could avoid the drawbacks of the standard techniques. OBJECTIVE: Comparison of antroduodenal stent, conventional gastrojejunostomy and gastric partitioning gastrojejunostomy. MATERIAL AND METHODS: A retrospective, cross-sectional study was conducted on patients with unresectable distal gastric cancer and gastric outlet obstruction, treated with the three different techniques over the last 12 years, comparing results based on oral tolerance and complications. An analysis was performed on the results using the Student-t test for independent variables. RESULTS: The 22 patients were divided in 3 groups: group I (6 cases) stent, group II (9 cases) conventional gastrojejunostomy, and group III (7 cases) gastric partitioning gastrojejunostomy, respectively. The stent allows a shorter "postoperative" stay and early onset of oral tolerance (P<0.05), however, the gastric partitioning gastrojejunostomy achieve normal diet at 15th day (P<0.05). The mortality rate was higher in the stent group (33%) compared with surgical techniques, with a morbidity of 4/6 (66.7%) in Group I, 6/9 (66.7%) Group II, and 3/7 (42%) Group III. Re-interventions: 2/6 Group I, 3/9 Group II, and 0/7 Group III. The median survival was superior in the gastric partitioning gastrojejunostomy, achieving an overall survival of 6.5 months. CONCLUSIONS: The gastric partitioning gastrojejunostomy for treatment of gastric outlet obstruction in unresectable advanced gastric cancer is a safe technique, allowing a more complete diet with lower morbidity and improved survival.

[Surgical access routes in enteral nutrition]. / Vías de acceso quirúrgico en nutrición enteral.

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Vías de acceso quirúrgico en nutrición enteral / Surgical access routes in enteral nutrition

Son múltiples las vías de acceso al tubo digestivo para la nutrición enteral (NE) que conocemos y que en los últimos años ha experimentado importantes avances. Igualmente han avanzado considerablemente tanto las técnicas de administración como los productos nutricionales. La colocación de estos sistemas puede ser temporal o permanente. Sus indicaciones a menudo se superponen. Si es factible, siempre la vía enteral es la preferida respecto de la parenteral. Si ésta es necesaria durante 6 semanas o menos, las sondas nasoenterales son la mejor opción, por el contrario, las sondas de enterostomía serían las indicadas en la NE que supere las 6 semanas y la gastrostomía endoscópica percutánea (PEG) es el procedimiento de elección. El acceso pospilórico debe considerarse en pacientes con alto riesgo de aspiración. Finalmente, la yeyunostomía con catéter fino en el curso de una intervención quirúrgica del tracto gastrointestinal superior es la técnica ideal para iniciar la NE precoz. Todas las técnicas continúan teniendo alguna vigencia y sólo la situación clínica del enfermo y la experiencia del equipo que los atiende determinarán su uso. Este trabajo consta de dos partes. En la primera se analizan las técnicas de acceso quirúrgico en NE, sus indicaciones, contraindicaciones y las complicaciones más frecuentes relacionadas con la técnica, con el cuidado del estoma y con el material de intubación. En la segunda se aportan datos de nuestra experiencia en el tema, con las diversas técnicas que hemos realizado, en qué pacientes y con qué resultados y complicaciones. En total, 287 procedimientos: 48 gastrostomías quirúrgicas, 40 según la técnica de Fontan o Stamm y 8 gastrostomías de Janeway, 27 de ellas permanentes; 169 catéteres de yeyunostomía con una permanencia media de 29,05 ± 21,9 días y 72 sondas nasoyeyunales de doble luz (AU)

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 ± 21.9 days, and 72 double lumen nasojejunal tubes (AU)