Abdominal Actinomycotic Abscess after Laparoscopic Sleeve Gastrectomy for Morbid Obesity: A Case Report.

Actinomycosis is a rare, chronic, suppurative, and granulomatous bacterial disease. The Actinomyces species exist as normal flora in the oropharynx, gastrointestinal tract, and the female genital tract. They are incapable of penetrating the normal mucous membranes and become pathogenic only when this barrier has been destroyed by trauma, surgery, immunosuppression, or after viscus perforation. We report the first case of an actinomycotic abscess after laparoscopic sleeve gastrectomy. A 29-year-old man underwent a laparoscopic sleeve gastrectomy with no intra-operative complications. On postoperative day 3, the patient had a fever with elevated inflammatory markers. Abdominal computerized tomography (CT) with oral water-soluble contrast media showed no extra-luminal leakage and no fluid collection adjacent to the resected stomach, other than the fluid collection in the right subhepatic space. Percutaneous drainage was attempted, but the procedure failed due to the patient's thick abdominal wall. After two weeks of weight loss of about 12 kg, percutaneous drainage was successfully performed, and A. odontolyticus was identified through pus culture. After effective abscess drainage and high-dose antibiotics, the patient's symptoms improved and the abscess pocket disappeared. We reported Actinomyces infection after gastric sleeve surgery. In the case of abscess formation after gastric sleeve surgery caused by actinomycete infection, antibiotic treatment and percutaneous drainage are effective together.

Exploring ideal operative time for best outcomes in gastric cancer surgery: A multi-institutional study based on KLASS-07 database.

Objective: While a rushed operation can omit essential procedures, prolonged operative time results in higher morbidity. Nevertheless, the optimal operative time range remains uncertain. This study aimed to estimate the ideal operative time range and evaluate its applicability in laparoscopic cancer surgery. Methods: A prospectively collected multicenter database of 397 patients who underwent laparoscopic distal gastrectomy were retrospectively reviewed. The ideal operative time range was statistically calculated by separately analyzing the operative time of uneventful surgeries. Finally, intraoperative and postoperative outcomes were compared among the shorter, ideal, and longer operative time groups. Results: The statistically calculated ideal operative time was 135.4-165.4 min. The longer operative time (LOT) group had a lower rate of uneventful, perfect surgery than the ideal or shorter operative time (IOT/SOT) group (2.8% vs. 8.8% and 2.2% vs. 13.4%, all P<0.05). Longer operative time increased bleeding, postoperative morbidities, and delayed diet and discharge (all P<0.05). Particularly, an uneventful, perfect surgery could not be achieved when the operative time exceeded 240 min. Regardless of ideal time range, SOT group achieved the highest percentage of uneventful surgery (13.4%), which was possible by surgeon's ability to retrieve a higher number of lymph nodes and perform ≥150 gastrectomies annually. Conclusions: Operative time longer than the ideal time range (especially ≥240 min) should be avoided. If the essential operative procedure were faithfully conducted without compromising oncological safety, an operative time shorter than the ideal range leaded to a better prognosis. Efforts to minimize operative time should be attempted with sufficient surgical experience.

Single port intra-gastric full thickness resection: Using "Rotation and Revolution Single Instrument Tie (RRSIT)".

BACKGROUND/AIMS: Recently, minimize incisions has led to a reduction in the number of ports, and has led to transumbilical single-port surgery. We evaluated the treatment result of single-port, intragastric, full thickness resections for gastric SMTs. In addition, we introduce a novel intracorporeal knot tying method. METHODOLOGY: From August 2010 to March 2011, five patients underwent single-port intragastric, full thickness gastric wedge resections. After performing a gastrostomy, a single port was inserted into the stomach. After full thickness resection, the defect in the gastric wall was sutured by full thickness interrupted suture and a new knot tying technique. RESULTS: The mean operative time was 129 ± 21.0 min and the mean mass size was 3.0±0.6 cm. There were two very low-risk GISTs, 2 leiomyomas, and 1 carcinoid. The post-operative course was uneventful in all patients. The mean hospital stay was 7.2±1.2 days. CONCLUSIONS: Single-port intra-gastric full thickness resection with novel intracorporeal knot tying method is feasible and safe. novel intracorporeal knot tying method is a very useful knot tying method. We expect the application of novel intracorporeal knot tying method to be diverse and broad.

Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07, a randomized controlled trial.

BACKGROUNDS: Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). We performed an RCT to confirm if TLDG is different from LADG. METHODS: The KLASS-07 trial is a multicentre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enrolled from 21 cancer care centers in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was QoL for 1 year. This trial is registered at ClinicalTrials.gov (NCT NCT03393182). RESULTS: 442 patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year. CONCLUSIONS: The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complication but has advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

The Impact of Overweight and Obesity on Reduced-Port Laparoscopic Distal Gastrectomy for Gastric Cancer Patients: A Propensity Score Matching Analysis of a Single-Institution Data.

This study aimed to investigate the short-term postoperative outcomes of reduced-port laparoscopic distal gastrectomy and demonstrate its safety and feasibility in overweight and obese patients with gastric cancer. The medical records of 211 patients who underwent reduced-port laparoscopic distal gastrectomy, between August 2014 and April 2020, were reviewed. After propensity score matching, they were divided into a non-overweight group (n = 68) and overweight group (n = 68). Operative details and short-term surgical outcomes were compared between two groups. Reduced-port laparoscopic distal gastrectomy in overweight group showed statistically longer operation time (200.59 vs. 208.68 min, p = 0.044), higher estimated bleeding volume (40.96 vs. 58.01 mL, p = 0.001), and lesser number of harvested lymph nodes (36.81 vs. 32.13, p = 0.039). However, no significant differences were found in hospital course and other surgical outcomes. There was no mortality in either group, and the postoperative morbidity rate was not significantly different (14.7% vs. 16.2%). In the subgroup analysis, overweight and obesity did not significantly affect postoperative complication rates (16.2% vs. 16.2%, p = 1). We demonstrated comparable short-term surgical outcomes of reduced-port laparoscopic distal gastrectomy between the two groups (p = 0.412~1). Reduced-port laparoscopic distal gastrectomy was safe in overweight and obese patients with gastric cancer.

Reduced-port laparoscopic distal gastrectomy in obese gastric cancer patients.

BACKGROUND: Reduced-port laparoscopic gastrectomy is currently widely performed for patients with gastric cancer. However, its safety in obese patients has not yet been verified. This is the first study on reduced-port laparoscopic distal gastrectomy (RpLDG) in obese patients with gastric cancer. This study aimed to evaluate the short-term surgical outcomes and investigate the feasibility and safety of RpLDG in obese patients with gastric carcinoma. MATERIAL AND METHODS: A total of 271 gastric cancer patients who underwent RpLDG at our institution were divided into two groups: non-obese [body mass index (BMI) <30 kg/m2, n = 251; NOG] and obese (BMI ≥30 kg/m2, n = 20; OG). The mean age of the enrolled patients was 64.8 ± 11.4 years, with 72.0% being men and 28.0% women. Operative details and short-term surgical outcomes, including hospital course and postoperative complications, were compared by retrospectively reviewing the medical records. RESULTS: No significant difference in operation time was found between the NOG and OG (205.9 ± 40.0 vs. 211.3 ± 37.3 minutes, P = 0.563). Other operative outcomes in the OG, including estimated blood loss (54.1 ± 86.1 vs. 54.0 ± 39.0 mL, P = 0.995) and retrieved lymph nodes (36.2 ± 16.4 vs. 35.5 ± 18.2, P = 0.875), were not inferior to those in the NOG. There were also no statistical differences in short-term surgical outcomes, including the incidence of surgical complications (13.9% vs. 10.0%, P = 1). CONCLUSION: RpLDG can be performed safely in obese gastric cancer patients by an experienced surgeon. It should be considered a feasible alternative to conventional port distal gastrectomy.

Transpyloric optic navigation of tumor using a laparoscope during totally laparoscopic distal gastrectomy for gastric cancer.

Purpose: The purpose of this study was to describe the technique of intraoperative transpyloric optic navigation (TPON) and determine its efficacy and feasibility during totally laparoscopic distal gastrectomy (TLDG) in patients with gastric cancer. Methods: Seventy-nine patients who underwent laparoscopic gastrectomy with transpyloric optic localization of the tumor from January 2016 through December 2018 were enrolled in this study. After resecting the first portion of the duodenum, the distal part of the stomach was exteriorized through an extended supraumbilical trocar site, and a balloon trocar was introduced from the pylorus to determine the location of tumor and determine its resection margin. The clinicopathologic and surgical outcomes were analyzed. Results: The tumor was located in the lower third of the stomach in 39 cases, the middle third in 34 cases, and the upper-third in six cases. Tumor localization was successful in 67 patients. The mean proximal margin was 41.7 ± 26.8 mm. There was no morbidity related to the technique. By the fifth postoperative day, the average white blood cell count was within the normal range and the average level of C-reactive protein showed a decreasing pattern. Conclusion: TPON of the tumor during TLDG is an effective and feasible method to determine the tumor location and to obtain an adequate resection margin.

Implementation of Enhanced Recovery after Surgery (ERAS) Program in Perioperative Management of Gastric Cancer Surgery: a Nationwide Survey in Korea.

PURPOSE: Despite its clinical benefits, enhanced recovery after surgery (ERAS) is less widely implemented for gastric cancer surgery. This nationwide survey investigated the current status of the implementation of ERAS in perioperative care for gastric cancer surgery in South Korea. MATERIALS AND METHODS: This survey enrolled 89 gastric surgeons from 52 institutions in South Korea. The questionnaire consisted of 24 questions about the implementation of the ERAS protocols in the management of gastric cancer surgery. The survey was carried out using an electronic form sent via email. RESULTS: Of the 89 gastric surgeons, 58 (65.2%) answered that they have knowledge of the concept and details of ERAS, 45 (50.6%) of whom were currently applying ERAS for their patients. Of the ERAS protocols, preoperative education (91.0%), avoidance of preoperative fasting (68.5%), maintenance of intraoperative normothermia (79.8%), thromboprophylaxis (96.5%), early active ambulation (64.4%), and early removal of urinary catheter (68.5%) were relatively well adopted in perioperative care. However, other practices, such as avoidance of preoperative bowel preparation (41.6%), provision of preoperative carbohydrate-rich drink (10.1%), avoidance of routine abdominal drainage (31.4%), epidural anesthesia (15.9%), single-dose prophylactic antibiotics (19.3%), postoperative high oxygen therapy (36.8%), early postoperative diet (14.6%), restricted intravenous fluid administration (53.9%), and application of discharge criteria (57.3%) were not very well adopted for patients. CONCLUSIONS: Perioperative management of gastric cancer surgery is largely heterogeneous among gastric surgeons in South Korea. Standard perioperative care based on scientific evidence needs to be established to improve the quality of surgical care and patient outcomes.

Transition from Conventional to Reduced-Port Laparoscopic Gastrectomy to Treat Gastric Carcinoma: a Single Surgeon's Experience from a Small-Volume Center.

PURPOSE: This study aimed to evaluate the surgical outcomes and investigate the feasibility of reduced-port laparoscopic gastrectomy using learning curve analysis in a small-volume center. MATERIALS AND METHODS: We reviewed 269 patients who underwent laparoscopic distal gastrectomy (LDG) for gastric carcinoma between 2012 and 2017. Among them, 159 patients underwent reduced-port laparoscopic gastrectomy. The cumulative sum technique was used for quantitative assessment of the learning curve. RESULTS: There were no statistically significant differences in the baseline characteristics of patients who underwent conventional and reduced-port LDG, and the operative time did not significantly differ between the groups. However, the amount of intraoperative bleeding was significantly lower in the reduced-port laparoscopic gastrectomy group (56.3 vs. 48.2 mL; P<0.001). There were no significant differences between the groups in terms of the first flatus time or length of hospital stay. Neither the incidence nor the severity of the complications significantly differed between the groups. The slope of the cumulative sum curve indicates the trend of learning performance. After 33 operations, the slope gently stabilized, which was regarded as the breakpoint of the learning curve. CONCLUSIONS: The surgical outcomes of reduced-port laparoscopic gastrectomy were comparable to those of conventional laparoscopic gastrectomy, suggesting that transition from conventional to reduced-port laparoscopic gastrectomy is feasible and safe, with a relatively short learning curve, in a small-volume center.

Surgical Outcomes of Laparoscopic Resection for Subepithelial Lesions on the Gastric Fundus Performed in the Supine or Lateral Decubitus Position.

BACKGROUND: Laparoscopic resection of gastric subepithelial lesions (SELs) located on the posterior wall of the gastric fundus is technically difficult and time-consuming. To facilitate access, we propose performing the laparoscopic procedure with patients in a right lateral decubitus position, rather than the standard supine position. The aim of our study was to compare operative and clinical outcomes for laparoscopic SEL resection performed in either the right lateral decubitus or the traditional supine position. METHODS: The analysis was based on the data of 62 patients who underwent laparoscopic resection of SELs of the gastric fundus at Chonnam National University Hospital: 30 patients in the supine position (SUP) group and 32 in the right lateral decubitus position (RLD) group. All surgeries were performed by a single surgeon. Between-group comparisons were evaluated by Student's t, chi-squared, or Fisher's least squared tests, as appropriate for the data set. RESULTS: Compared with the SUP group, the RLD had shorter operative time (103 minutes versus 52 minutes, P < .001), less intraoperative blood loss (71 mL versus 31 mL, P < .001), and lower C-reactive protein levels on postoperative days 1 and 2 (P < .005). Time to first flatus and length of hospital stay were comparable between groups. CONCLUSION: Laparoscopic gastric wedge resection for SELs on the gastric fundus in the right lateral decubitus position is feasible and safe, and provides operative advantages over the supine position.

Adverse prognostic impact of splenectomy on survival in gastric carcinoma patients: Regression and propensity score matching analysis of 1074 patients.

BACKGROUNDS: Patients with proximal gastric carcinoma undergo total gastrectomy with concomitant splenectomy to ensure the complete removal of splenic hilar lymph nodes. However, the impact of splenectomy on survival remains uncertain. This study aimed to investigate the impact of splenectomy on survival among patients with gastric carcinoma. METHODS: Of 1074 patients who underwent total gastrectomy for proximal gastric carcinoma between 2006 and 2014, 229 patients underwent concomitant splenectomy or pancreaticosplenectomy during surgery. We investigated the prognostic impact of splenectomy using a regression and propensity score matched model. RESULTS: The splenectomy and non-splenectomy groups differed in many baseline characteristics, including tumor stage, and had respective crude 5-year survival rates of 55% and 81% (p <0.001). In a multivariate analysis adjusted for TNM stage and other prognostic factors, splenectomy was an independent poor prognostic factor for overall survival (hazard ratio [HR] = 1.67, 95% confidence interval [CI] = 1.11-2.51) and disease-free survival (HR = 1.61, 95% CI = 1.24-2.10). A survival evaluation stratified by TNM stage showed that splenectomy adversely affected survival among patients with stage III, but not stage I, II, and IV disease. In the propensity score-matched sample, splenectomy group also showed significantly worse overall survival (5-year, 65% vs. 79%, p = 0.010) and disease-free survival (5-year, 55% vs. 72%, p = 0.025) and was an independent poor prognostic factor in a multivariate analysis adjusting TNM stage and other prognostic factors. CONCLUSIONS: Splenectomy adversely affects survival, particularly among patients with stage III gastric carcinoma, and should be avoided unless there is direct invasion to the splenic hilum.

Quantitative analysis of COX-2 promoter methylation in gastric carcinoma.

PURPOSE: To determine the occurrence of COX-2 methylation in gastric carcinoma (GC), the status and level of CpG methylation in the promoter region of cyclooxygenase-2 (COX-2) were analyzed in early and advanced GCs, as well as in normal gastric tissues. METHODS: The extent of promoter methylation of the COX-2 gene was assessed quantitatively using pyrosequencing in 60 early and 60 advanced GCs samples harvested upon gastrectomy, and 40 normal gastric mucosa samples from patients with benign gastric diseases as controls. RESULTS: The methylation frequency for the COX-2 gene was significantly higher in early than in advanced GCs (40.0% vs. 20.0%, P < 0.05). A significant difference was found in COX-2 methylation between GCs and normal gastric tissues (30.0% vs. 10.0%, by PS; P < 0.05). COX-2 gene methylation was significantly associated with the depth of invasion (P = 0.003), lymph node metastasis (P = 0.009), distant metastasis (P = 0.036), and TNM staging (P = 0.007). The overall survival of patients with COX-2 methylation was significantly lower than that of patients without COX-2 methylation (P = 0.005). CONCLUSION: These results demonstrated that COX-2 promoter methylation was significantly higher in tumor tissues, and was an early event for GC, thus, COX-2 gene methylation may be important in the initial development of gastric carcinogenesis. Thus, GCs with methylation in COX-2 may not be good candidates for treatment with COX-2 inhibitors. Furthermore, COX-2 methylation could be a significant prognostic factor predicting a favorable effect on GC patient outcome when downregulated.

Is Laparoscopy-assisted Radical Gastrectomy Safe in Patients with Child-Pugh Class A Cirrhosis?

PURPOSE: We investigated early postoperative morbidity and mortality in patients with liver cirrhosis who had undergone radical gastrectomy for gastric cancer. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients who underwent radical gastrectomy at the Chonnam National University Hwasun Hospital (Hwasun-gun, Korea) between August 2004 and June 2009. There were few patients with Child-Pugh class B or C; therefore, we restricted patient selection to those with Child-Pugh class A. RESULTS: Postoperative complications were observed in 22 (53.7%) patients. The most common complications were ascites (46.3%), postoperative hemorrhage (22.0%) and wound infection (12.2%). Intra-abdominal abscess developed in one (2.4%) patient who had undergone open gastrectomy. Massive ascites occurred in 4 (9.8%) patients. Of the patients who underwent open gastrectomy, nine (21.9%) patients required blood transfusions as a result of postoperative hemorrhage. However, most of these patients had advanced gastric cancer. In contrast, most patients who underwent laparoscopic gastrectomy had early stage gastric cancer, and when the confounding effect from the different stages between the two groups was corrected statistically, no statistically significant difference was found. There was also no significant difference between open and laparoscopic gastrectomy in the occurrence rate of other postoperative complications such as ascites, wound infection, and intra-abdominal abscess. No postoperative mortality occurred. CONCLUSIONS: Laparoscopic gastrectomy is a feasible surgical procedure for patients with moderate hepatic dysfunction.

Multivisceral resection for locally advanced rectal cancer: adequate length of distal resection margin.

PURPOSE: Locally advanced rectal cancer may require an intraoperative decision regarding curative multivisceral resection (MVR) of adjacent organs. In bulky tumor cases, ensuring sufficient distal resection margin (DRM) for achievement of oncologic safety is very difficult. This study is designed to evaluate the adequate length of DRM in multiviscerally resected rectal cancer. METHODS: A total of 324 patients who underwent curative low anterior resection for primary pT3-4 rectal cancer between 1995 and 2004 were identified from a prospectively collected colorectal database. RESULTS: Short lengths of DRM (≤1 cm) did not compromise essentially poor oncologic outcomes in locally advanced rectal cancer (P = 0.736). However, especially in rectal cancers invading adjacent organs, DRM of less than 2 cm showed poor survival outcome. In 5-year and 10-year survival analysis of MVR, a shorter DRM (<2 cm) showed 41.9% and 30.5%, although a longer DRM (≥2 cm) showed 72.4% and 60.2% (P = 0.03, 0.044). In multivariate analysis of MVR, poorly differentiated histology, ulceroinfiltrative growth of tumor, and short DRM (<2 cm) were significant factors for prediction of poor survival outcome, although short DRM was not significantly related to local and systemic recurrence. CONCLUSION: In locally advanced rectal cancer of pT3-4, a short length of DRM (≤1 cm) did not compromise essentially poor oncologic outcome. In rectal cancers invading adjacent organs and requiring MVR, a shorter DRM (<2 cm) was found to be related to poor survival outcome.

Preoperative predictors of malignant gastric submucosal tumor.

PURPOSE: The preoperative prediction of malignant potential in patients with gastric submucosal tumors (SMTs) plays an important role in decisions regarding their surgical management. METHODS: We evaluated the predictors of malignant gastric SMTs in 314 patients with gastric SMTs who underwent surgery in Chonnam National University Hospital. RESULTS: The malignant SMTs were significantly associated with age (odds ratio [OR], 1.067; 95% confidence interval [CI], 1.042 to 1.091; P < 0.0001), presence of central ulceration (OR, 2.690; 95% CI, 1.224 to 5.909; P = 0.014), and tumor size (OR, 1.791; 95% CI, 1.483 to 2.164; P < 0.0001). Receiver operating characteristic curve analysis showed that tumor size was a good predictor of malignant potential. The most relevant predictor of malignant gastric SMT was tumor size with cut-offs of 4.05 and 6.40 cm. CONCLUSION: Our findings indicated that age, central ulceration, and tumor size were significant preoperative predictors of malignant SMTs. We suggest that 4 cm be selected as a threshold value for malignant gastric SMTs. In patients with a gastric SMT larger than 4 cm with ulceration, wide resection of the full thickness of the gastric wall or gastrectomy with adequate margins should be performed because of its malignant potential.

Clinicopathological features of female gastric carcinoma patients with curative resection: comparison with male patients.

Little is known about the clinicopathological features of female gastric carcinoma (FGC) patients. We compared the clinicopathologic features and outcomes of FGC patients with curative resection with those of male gastric carcinoma (MGC) patients. We reviewed the hospital records of 940 FGC patients between 1986 and 2005 at Chonnam National University Hospital. Multivariate analysis showed that presence of serosal invasion, lymph node metastasis, and operative type were significant prognostic factors for survival of FGC patients with curative resection. Furthermore, the overall 5-year survival rate of FGC patients with curative resection (53.4%) was higher than that of MGC patients (47.6%, p<0.05). In advanced cases, no significant difference was observed in the overall 5-year survival rate between the FGC and MGC patients (41.6% vs 37.4%, p>0.05). Therefore, serosal invasion, lymph node metastasis, and type of operation were statistically significant parameters associated with survival. Early detection is more important for improving the prognosis of female patients with gastric cancer than for male patients.