Evaluation of Quality of Life and Prognosis of Gastric Cancer Patients After Laparoscopic Subtotal Gastrectomy.

BACKGROUND/AIM: The clinical significance of laparoscopic subtotal gastrectomy (LsTG) with a small remnant stomach remains unclear in patients with gastric cancer, including at an advanced stage. The present study assessed postoperative quality of life (QOL) and survival after LsTG compared with laparoscopic total gastrectomy (LTG). PATIENTS AND METHODS: We retrospectively analyzed consecutive patients with gastric cancer who underwent LsTG (n=26) or LTG (n=26). Surgical outcome, postoperative nutritional status, QOL, and prognosis were compared between the LsTG and LTG groups. The Postgastrectomy Syndrome Assessment Scale was used to evaluate postoperative QOL. RESULTS: Operating time was significantly shorter (p<0.01) and postoperative morbidity was significantly lower (p=0.04) in the LsTG than in the LTG group. The reduction in body weight after surgery was significantly greater in the LTG than in the LsTG group (p<0.01). The Postgastrectomy Syndrome Assessment Scale revealed that, compared with LTG, LsTG significantly improved postoperative QOL (p<0.05). There was no significant difference in relapse-free survival and cancer-specific survival between the two groups. Three patients in the LTG group died of pneumonia and overall survival was significantly longer in the LsTG group (p=0.01). CONCLUSION: This study demonstrated the efficacy of LsTG with a small remnant stomach to prevent a decline in postoperative QOL and non-cancer-related death.

Clinical Relevance of Proximal Gastrectomy With Double-flap Esophagogastrostomy Reconstruction With Glycemic Profile and Postgastrectomy Syndromes.

BACKGROUND/AIM: The glycemic profile of patients who have undergone proximal gastrectomy (PG) using a continuous glucose monitoring (CGM) device has not been investigated. We aimed to investigate the association between postgastrectomy syndrome and the glycemic profile of patients who underwent PG and its impact on postoperative body weight loss and nutritional status. PATIENTS AND METHODS: We retrospectively investigated 65 patients with CGM post-surgery. Postoperative glycemic profiles were recorded using a CGM device. To evaluate postgastrectomy syndromes and quality of life (QOL), the Postgastrectomy Syndrome Assessment Scale 37-item questionnaire was employed. The dynamics of albumin and hemoglobin levels were investigated at 1 and 6 months postoperatively. RESULTS: The time below the range (percentage of glucose reading <70 mg/dl) in patients who underwent PG with double-flap (DF) esophagogastrostomy reconstruction was significantly shorter than in those who underwent total gastrectomy (TG). Late dumping scores tended to be better in patients after PG with DF than in those after TG. The body weight loss rate of patients who underwent PG with DF was similar to those who underwent TG. The albumin level at 6 months recovered to the preoperative level in patients who underwent PG with DF, but not in those who underwent TG. Hemoglobin levels at 1 and 6 months postoperatively were significantly higher in patients who underwent PG with DF than in those who underwent TG. CONCLUSION: Proximal gastrectomy with double-flap esophagogastrostomy reconstruction did not improve QOL or body weight loss, as expected, however, suppressed hypoglycemia, late dumping syndrome, and deterioration in nutritional status.

A comparison of the effects of anti-reflux procedures during esophagogastrostomy after proximal gastrectomy on the postoperative quality of life.

PURPOSE: To investigate the postoperative quality of life (QOL) in patients with proximal gastric cancer (PGC) or esophago-gastric junction cancer, a nationwide multi-institutional study (PGSAS NEXT trial) was conducted. METHODS: Patients who had undergone radical resection more than 6 months previously were enrolled from 70 Japanese institutions between July 2018 and June 2020. The Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 questionnaire was distributed to eligible patients, and responses were collected by mail. The main outcome measures of the PGSAS-45 were then calculated and compared. RESULTS: Questionnaires were retrieved from 1950 participants, and data from 300 patients who had undergone a proximal gastrectomy (PG) with esophagogastrostomy for PGC were analyzed. The mean esophageal reflux subscale value was 1.9 among the 276 patients who underwent an anti-reflux procedure, which was significantly better than the mean value (2.6) for the 21 patients who did not undergo an anti-reflux procedure (p = 0.002). The esophageal reflux subscale values were also compared among 3 major anti-reflux procedures: the double-flap technique (N = 153), the pseudo-fornix and/or His angle formation (N = 67), and fundoplication (N = 44); no statistically significant differences were observed. CONCLUSION: An anti-reflux procedure during esophagogastrostomy after PG for PGC is necessary to improve postoperative esophageal reflux symptoms, regardless of the type of procedure. TRIAL REGISTRATION: The PGSAS NEXT study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Optimal Procedures for Double Tract Reconstruction After Proximal Gastrectomy Assessed by Postgastrectomy Syndrome Assessment Scale-45.

BACKGROUND: Although double tract reconstruction after proximal gastrectomy (PGDT) is commonly performed for proximal gastric or esophagogastric junction cancer, the impact of the procedure on postoperative quality of life (QOL) has not been clarified. We aimed to clarify the optimal PGDT procedure in terms of postoperative QOL. METHODS: Postoperative QOL was analyzed in 172 patients who underwent PGDT for proximal gastric cancer and were enrolled in the PGSAS-NEXT study, a multicenter cross-sectional study in Japan (UMIN000032221), in relation to the remnant stomach size, length of interposed jejunum between the esophagojejunostomy (E-J) and jejunogastrostomy (J-G), and size of the J-G. RESULTS: The remnant stomach size was approximately one-third in 13, half in 97, and two-thirds in 60 patients. Dissatisfaction scores for symptoms, diet, work, and daily life subscales were lower in patients with a larger stomach (p < 0.05). These patients also scored better in terms of weight loss (- 13.5%, - 14.0%, and - 11.2%, respectively) and amount of food ingested per meal (52%, 62%, and 66%). The length of the interposed jejunum was ≤ 10 cm in 62 and ≥ 11 cm in 97 patients. Weight loss (- 11.3% and - 13.8%) and dissatisfaction scores were better in the ≤ 10 cm group (p < 0.05). J-G size was ≤ 5 cm in 27 and ≥ 6 cm in 135 patients. The amount of food ingested (56%, 64%) and dissatisfaction scores were better in the > 6 cm group (p < 0.05). CONCLUSIONS: Larger remnant stomach, shorter length of interposed jejunum, and longer J-G might contribute to better postoperative QOL after PGDT.

Effects of Proximal Gastrectomy and Various Clinical Factors on Postoperative Quality of Life for Upper-third Gastric Cancer Assessed using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45): A PGSAS NEXT Study.

BACKGROUND: It is important to determine the effect of clinical factors on several domains (symptoms, living status, and quality of life [QOL]) after gastrectomy to establish individualized therapeutic strategies. This study was designed to determine the factors-particularly surgical method-that influence certain domains after gastrectomy for proximal gastric cancer by using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire. METHODS: We conducted a nationwide study of PGSAS-45 questionnaire responses retrieved from 1950 (82.5%) patients from 70 institutions who had undergone gastrectomy for gastric cancer. Of these, 1,538 responses for proximal gastric cancer (1020 total gastrectomies and 518 proximal gastrectomies [PGs]) were examined. RESULTS: PG significantly and favorably affected four main outcome measures (MOMs): elderly affected 10 MOMs, male sex affected 4 MOMs, longer postoperative period affected 8 MOMs, preservation of the vagus nerve affected 1 MOM, adjuvant chemotherapy affected 1 MOM, clinical stage affected 2 MOMs, and more extensive lymph node dissection affected 2 MOMs. However, the laparoscopic approach had an adverse effect on MOMs and combined resection of other organs had no favorable effect on any MOMs. CONCLUSIONS: This PGSAS NEXT study showed that it is better to perform PG for proximal gastric cancer, even for patients with advanced cancer, to obtain favorable postoperative QOL if oncological safety is guaranteed. Because the MOMs of PGSAS-45 are positively and negatively influenced by various background factors, it also is necessary to provide personalized care for each patient to prevent deterioration and further improve symptoms, living status, and QOL postoperatively.

The evaluation of the postoperative quality of life in patients undergoing radical gastrectomy for esophagogastric junction cancer using the Postgastrectomy Syndrome Assessment Scale-45: a nationwide multi-institutional study.

PURPOSE: This retrospective nationwide survey investigated the quality of life (QOL) of patients with esophagogastric junction cancer after gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45. METHODS: The Postgastrectomy Syndrome Assessment Scale-45 comprises 45 questions classified into symptoms, living status, and QOL domains. A total of 1950 gastrectomized patients with upper-third gastric or esophagogastric junction cancer returned the completed forms. Among them, 224 eligible patients with esophagogastric junction cancer were selected, including 86, 120, and 18 patients who underwent total gastrectomy, proximal gastrectomy (reconstruction-esophagogastrostomy: 56; double-tract method: 51), and other procedures, respectively. RESULTS: The postoperative period was significantly shorter (47 ± 30 vs. 34 ± 30 months, p = 0.002), and the rates of early-stage disease and minimally invasive approaches significantly higher (both p < 0.001) in the proximal gastrectomy group than in the total gastrectomy group. Despite advantageous background factors for proximal gastrectomy, the postoperative QOL did not differ markedly between the groups. Compared to patients who underwent reconstruction with the double-tract method, patients who underwent esophagogastrostomy had significantly larger remnant stomachs but a similar QOL. CONCLUSION: Even with total gastrectomy, a postoperative QOL comparable to that with proximal gastrectomy can be maintained. Clarifying the optimal reconstruction methods for proximal gastrectomy for esophagogastric junction cancer is warranted. TRIAL REGISTRATION: This study was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

BACKGROUND: Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. METHODS: Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6 days (range 1-30 days), and median duration of hospitalization was 13 days (range 3-135 days). At the follow-up (mean 24.6 months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. CONCLUSIONS: Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

Postgastrectomy Syndromes and Nutritional Considerations Following Gastric Surgery.

Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.

Endoluminal Revision (OverStitch (TM) , Apollo Endosurgery) of the Dilated Gastroenterostomy in Patients with Late Dumping Syndrome After Proximal Roux-en-Y Gastric Bypass.

Dumping syndrome is a long-term postoperative complication of Roux-en-Y gastric bypass procedures. Morphologically, dumping syndrome usually correlates with a dilatation of the gastroenterostomy with accelerated pouch emptying. Conservative therapy includes diet changes, complementary pharmacotherapy and, if symptoms persist, surgical revision. Surgical options include endoscopic, endoluminal surgery to constrict the gastrojejunostomy using a novel endoscopic suturing device (OverStitch(TM), Apollo). In our study, we aimed to assess the viability, safety and efficacy of this procedure in patients with late dumping; 14 patients who had developed late dumping syndrome underwent surgery using an endoscopic suturing technique (OverStitch(TM), Apollo). Late dumping was confirmed by Sigstad score and an oral glucose tolerance test (OGTT). Prior to surgery, objective analysis of pouch emptying speed was assessed by gastric scintigraphy. Surgery was performed under general anaesthesia. None of the 14 patients suffered intra- or postoperative complications. No postsurgical increase in inflammation parameters was observed. The postinterventional pain scale (visual analogue scale) showed a mean score of 0.5 (range 0-10). In 13 of the 14 patients, no dumping was observed 1-month postsurgery. The postoperative Sigstad score (3.07 ± 2.06; range 1-9) showed an impressive reduction compared with the preoperative score (12.71 ± 4.18; range 7-24) (p < 0.001). Postoperative upper gastrointestinal gastrografin swallow revealed regular emptying in all the patients. The endoluminal endoscopic suturing technique-applied here for surgical revision of gastroenterostomy following Roux-en-Y gastric bypass-represents a promising, novel therapeutic option in late dumping syndrome involving minimal trauma and offering rapid reconvalescence.

Retrograde jejunal intussusception after total gastrectomy: A case report and literature review.

Retrograde jejunal intussusception is a rare disease. A 60-year-old female patient was hospitalized due to vomiting for 2 days, with a history of radical gastrectomy plus esophagus jejunum Rouxs-en-Y. On examination, there was a palpable wax-like mass on the left-hand side underneath the umbilicus. Computerized tomography scan showed a proximal jejunal intussusception. During surgery, the distal jejunum was found set into the proximal jejunum for a length of 30 cm, and bowel necrosis was also observed. The necrotic tube was resected and anastomosis was performed. Four days after the surgery, gastrointestinal function resumed. After a 10-month follow-up, the patient had no discomfort.

Complicated gallstones after laparoscopic sleeve gastrectomy.

BACKGROUND: The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. METHODS: A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. RESULTS: Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3-8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. CONCLUSION: A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.

[Nutritional support in surgical treatment of patients with post-gastroresection and post-gastrectomy syndromes].

The aim of the research determine the character and peculiarities of nutritional support in surgical treatment of patients with gastroresection--and total gastrectomy syndromes. Analyzed are the results of the evaluation nourishing status of 68 patients who have had a resection intervention on the stomach. It was noted that the 26.5% of patients with clinical manifestations of diseases of operated stomach arise sub- and decompensated forms of disorders metabolism and nutrition, entailing numerous violations of homeostasis and requiring compliance with reconstructive surgical interventions. We studied the results of the implementation of the reconstructive operations with the formation of functionally active (see text for symbol) in 18 patients, suffering from the disease of stomach operated on. It is proved, that the rational nutritional support in the perioperative period allows to avoid gross violations of metabolism and provides a reasonably good compensation digestive function, significantly improving the quality of life of this category of patients.

[The substantiation of the method of gastrointestinal reconstruction after the gastric resection].

Functional results of 289 major gastric resections and gastrectomies were analyzed. New methods of the gastrointestinal reconstruction after these procedures. The comparative analysis of immediate and long-term results allowed to work out criteria of choice for the reconstructive procedure. Benefits of the suggested reconstructive techniques demonstrated with the use of modern diagnostic means.

Management of jejunal pouch dysfunction following total gastrectomy and Roux-en-Y reconstruction for gastric cancer: a case report.

INTRODUCTION: Total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction is a well recognised procedure for patients undergoing curative resections for gastric malignancy. The formation of a jejunal pouch is thought by some to create a reservoir that, when compared with straight oesophagojejunal anastomosis, reduces the incidence of post-operative dumping. CASE HISTORY: A patient presented two years after a total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction for a T3N2M0 adenocarcinoma of the stomach, with postprandial vomiting and dysphagia resulting in massive weight loss and malnutrition. Recurrent cancer and stricturing was ruled out by gastroscopy and computed tomography, and distal obstruction was ruled out by an oral contrast study. The diagnosis of a functional jejunal pouch disorder was made by exclusion. Balloon dilatation of the pouch and the oesophagojejunal anastomosis found little symptomatic improvement. The patient's deteriorating nutritional status prompted us to urgently perform revisional surgery. A re-laparotomy and pouch-jejunal bypass procedure was performed. Post-operatively, the patient made a full symptomatic recovery and began gaining weight. CONCLUSIONS: A pouch-enteric bypass is a suitable treatment option for patients with functional jejunal pouch dysmotility following a total gastrectomy and jejunal pouch formation in the absence of distal obstruction and recurrent disease.

Postgastrectomy syndromes.

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

[The Roux reconstruction for the correction of postresectional and postgastrectomy syndromes].

The study substantiates the efficacy of the Roux reconstruction of the upper gastrointestinal tract in the surgical treatment of postresectional and postgastrectomic syndromes. Such reconstructive operations were performed in 16 patients. There were no postoperative mortality or specific complications registered. The short and long-term follow up demonstrated good compensation of the disorders, caused by the earlier radical gastric surgery. Thus, the method of the Roux reconstruction, amplified by the creation of functionally active sphincters and valves provides the satisfactory relief of the operated stomach disease.

Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass.

INTRODUCTION: Rapid weight loss after Roux-en-Y gastric bypass (RYGBP) often is associated with gallstones formation, which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the gastric remnant for an endoscopic retrograde cholangiopancreatography (ERCP). CASE REPORT: A 40-year-old woman with a BMI of 48 kg/m(2), was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. In April 2007, she was admitted for upper right side abdominal pain, vomiting episodes, fever, and jaundice; the BMI at the time was 24 kg/m(2). Hepatic ultrasound showed lithiasis of the common bile duct with intra- and extrahepatic bile duct dilation, as well as gallbladder lithiasis. The patient was taken to the operating room for laparoscopic evaluation. A pursestring suture was performed on the greater curvature of the gastric remnant. After the opening of the stomach, an 18-mm trocar was inserted into the lumen and the endoscope was directly passed through the port into the duodenum. An ERCP was performed under fluoroscopic guidance, and as a result of sphincterotomy the stone was retrieved. After removing the endoscope, the gastrotomy was closed by tying the pursestring. Cholecystectomy was performed as well. RESULTS: The procedure lasted 98 min. Liver function tests returned normal on postoperative day 2, and the patient was discharged on postoperative day 4. After 9 months, the patient was well and asymptomatic. CONCLUSIONS: Patients previously submitted to RYGBP and presenting choledocholithiasis can benefit from an ERCP through the gastric remnant.

Results of completion gastrectomies in 44 patients with postsurgical gastric atony.

INTRODUCTION: Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure. METHODS: From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function. RESULTS: Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale). CONCLUSION: Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.

Laparoscopic exploration of common bile duct in post-gastrectomy patients.

BACKGROUND/AIMS: To evaluate the results of laparoscopic exploration of the common bile duct (LECBD) in patients with previous gastrectomy. METHODOLOGY: This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994-2005. Those cases of LECBD with previous open gastrectomy were sorted out and analyzed. Indications of operation included unsuccessful endoscopic extraction due to altered anatomy and some explorations were performed together with side-to-side choledochoduodenostomy so as to eliminate biliary stasis and decrease stone recurrence. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. After confirmed ductal clearance, the common bile duct was routinely closed with t-tube diversion. The perioperative parameters of these patients were analyzed and compared to those receiving open exploration of common bile duct due to previous gastrectomy during the same study period. RESULTS: Of the 184 LECBD performed between 1994 and 2005, 33 patients had previous open upper gastrointestinal operations and among them 18 LECBD were performed in post-gastrectomy patients (2 with previous classical Whipple's operation). There were 10 male and 8 female patients with mean age of 77.5 (58-97 years). Of the 14 patients undergoing preoperative endoscopic retrograde cholangiopancreatography, there were 10 failed cannulations and 4 failed extractions. Altogether 17 choledochotomies and 1 transcystic duct exploration was performed whereas 4 patients with recurrent primary stones received additional choledochoduodenostomy. Median operating time was 120 min (60-390 min). Open conversion was required in 3 patients (16.6%) because of jammed basket, extensive adhesion and "through & through" bile duct injury respectively. Postoperative complications occurred in 4 patients (22.2%), which included 3 bile leaks and also the previously mentioned bile duct injury. The median hospital stay was 9 days (4-82 days). Upon a median follow-up of 17.5 months, there was only 1 patient found to have recurrent common bile duct stone and he was managed by laparoscopic exploration and choledochoduodenostomy. When the results were compared to those 12 open explorations because of previous open gastrectomy, longer operation time (120 vs. 75 min, p=0.004) and slightly shorter hospital stay (9 vs. 14 days, p=0.104) were noted in the LECBD group but without increased complication rate (22.2 vs. 25%, p=1). CONCLUSIONS: These results suggest that LECBD is worth attempting even in patients with previous open gastrectomy.