Identification of prognostic signatures in remnant gastric cancer through an interpretable risk model based on machine learning: a multicenter cohort study.

OBJECTIVE: The purpose of this study was to develop an individual survival prediction model based on multiple machine learning (ML) algorithms to predict survival probability for remnant gastric cancer (RGC). METHODS: Clinicopathologic data of 286 patients with RGC undergoing operation (radical resection and palliative resection) from a multi-institution database were enrolled and analyzed retrospectively. These individuals were split into training (80%) and test cohort (20%) by using random allocation. Nine commonly used ML methods were employed to construct survival prediction models. Algorithm performance was estimated by analyzing accuracy, precision, recall, F1-score, area under the receiver operating characteristic curve (AUC), confusion matrices, five-fold cross-validation, decision curve analysis (DCA), and calibration curve. The best model was selected through appropriate verification and validation and was suitably explained by the SHapley Additive exPlanations (SHAP) approach. RESULTS: Compared with the traditional methods, the RGC survival prediction models employing ML exhibited good performance. Except for the decision tree model, all other models performed well, with a mean ROC AUC above 0.7. The DCA findings suggest that the developed models have the potential to enhance clinical decision-making processes, thereby improving patient outcomes. The calibration curve reveals that all models except the decision tree model displayed commendable predictive performance. Through CatBoost-based modeling and SHAP analysis, the five-year survival probability is significantly influenced by several factors: the lymph node ratio (LNR), T stage, tumor size, resection margins, perineural invasion, and distant metastasis. CONCLUSIONS: This study established predictive models for survival probability at five years in RGC patients based on ML algorithms which showed high accuracy and applicative value.

Efficacy of transcatheter arterial embolization in treating nonvariceal gastric remnant bleeding: a retrospective 5-year study.

BACKGROUND: Gastric remnant bleeding is a special case of upper gastrointestinal bleeding with certain specific disease characteristics, and some matters of transcatheter arterial embolization (TAE) for hemostasis need attention. In this study, we aimed to explore the clinical use of TAE in patients with nonvariceal gastric remnant bleeding and identify the factors influencing the clinical efficacy of these interventions. METHODS: Data were retrospectively analyzed from 42 patients for whom angiography and embolization were performed but could not be treated endoscopically or had failed endoscopic management in our department between January 2018 and January 2023 due to nonvariceal gastric remnant bleeding. We investigated the relationship between the incidence of re-bleeding and the following variables: sex, age, pre-embolization gastroscopy/contrast-enhanced computer tomography, embolization method, aortography performance, use of endoscopic titanium clips, and the presence of collateral gastric-supplying arteries. RESULTS: Forty-two patients underwent 47 interventional embolizations. Of these, 16 were positive for angiographic findings, and 26 were negative. Based on arteriography results, different embolic agents were selected, and the technical success rate was 100%. The incidence of postoperative re-bleeding was 19.1% (9/47), and the overall clinical success rate was 81.0% (34/42). Logistic regression analysis of the relationship between the incidence of early re-bleeding following embolization and the proportion of collateral gastric supply arteries revealed an odds ratio of 10.000 (p = 0.014). CONCLUSIONS: Utilizing TAE for nonvariceal gastric remnant bleeding is safe and effective. The omission of collateral gastric-supplying arteries can lead to early re-bleeding following an intervention.

Incidence and risk of remnant gastric cancer after gastrectomy for gastric cancer: a population-based study from the SEER database.

BACKGROUND: Gastric cancer (GC) constitutes a major global health problem, of which remnant gastric cancer (RGC) occurs less frequently. The rate of RGCs after gastrectomy for GC is increasing recently due to improved survival and screening, however, their incidence and risk have not been reported in the U.S. POPULATION: The objective of this study was to evaluate the incidence and elevated risk of RGC after GC gastrectomy in this population, and to identify the risk factors. METHODS: Patients underwent gastrectomy for first primary GC in 2000-2015 and those who developed RGC were identified from Surveillance, Epidemiology and End Results (SEER) database. Fine-Gray regression was used to estimate the cumulative incidence and to identify risk factors. Standardized incidence ratios (SIRs) were calculated by Poisson regression to compare the risk with the general population. RESULTS: Among 21,566 patients included in the cohort, 227 developed RGC. The 20-year cumulative incidence of RGC was 1.88%. Multivariate analysis revealed that older age, invasion depth, male sex, marital status, and lower income are independent risk factors for RGC development. SIR was 7.70 overall and > 4.5 in each stratum. CONCLUSIONS: Cumulative incidence and risk for RGCs increased continuously in patients underwent GC gastrectomy. Close and lifelong endoscopy surveillance should be recommended for patients who received GC gastrectomy, especially those with high-risk factors.

[Double-tract reconstruction after gastrectomy for gastric cancer in patients with concomitant cardiovascular diseases]. / Rekonstruktsiya double-tract posle gastrektomii po povodu raka zheludka u patsientov s konkuriruyushchimi serdechno-sosudistymi zabolevaniyami.

OBJECTIVE: To demonstrate the capabilities and advantages of double-tract reconstruction after gastrectomy for gastric cancer and simultaneous approach in surgical treatment of patients with cardiovascular diseases and gastric cancer. MATERIAL AND METHODS: We present two cases of double-tract reconstruction after gastrectomy and the gastric stump extirpation as a part of simultaneous surgical approach to patients with gastric cancer and cardiovascular diseases. A 62-year-old patient underwent simultaneous gastrectomy with double-tract reconstruction (for the first time In Russia) and aortofemoral replacement. A 61-year-old patient underwent simultaneous coronary artery bypass surgery, gastric stump extirpation with esophagogastrostomy and double-tract reconstruction. RESULTS: In 1 case, postoperative period was complicated by subcompensated stenosis of the right ureter due to hematoma near the right common iliac artery. This event required endoscopic stenting of the right ureter with positive effect. Both patients were discharged in 16 and 23 days after surgery. CONCLUSION: This method may be alternative to modern reconstructions. Currently, digestive tract reconstruction after gastrectomy is still important and requires further study. Simultaneous procedures in patients with cancer and cardiovascular disease became more widespread. To objectify our statements, further research is needed.

Robotic Splenic Vessels Preserving Distal Pancreatectomy in a Post-Distal Gastrectomy Patient.

BACKGROUND: The optimal procedure during distal pancreatectomy (DP) for patients who have undergone distal gastrectomy (DG) remains unclear. Several papers on remnant gastric ischemia have reported that the preserved splenic vessels are essential for the proximal remnant stomach.1-4 We evaluated the outcomes of DP for post-DG patients in our hospital and introduced robotic splenic vessels preserving DP (R-SPDP). METHODS: Postoperative short-term outcomes of DP for post-DG patients during 2014 and 2021 were evaluated. Next, R-SPDP was performed for a post-DG patient with the intention of preserving the remnant stomach safely. The double bipolar method was used to dissect the adhesions around the splenic vessels.5,6 The splenic artery was clamped at the root side to prevent bleeding.7 All short gastric arteries and veins, which were the main feeders of the remnant stomach, were preserved and resection was completed. After resection, the indocyanine green (ICG) fluorescence angiography confirmed blood flow in the short gastric arteries and veins and good return blood flow to the splenic vein.8 RESULTS: Of four patients (50.0%, of 8 DP patients) in whom the remnant stomach was preserved, one conventional DP case had poor ICG perfusion and presented with remnant stomach ischemia postoperatively. The R-SPDP case with good ICG perfusion had a total operation time of 371 minutes and intraoperative blood loss of 10 mL. The oral diet was started on postoperative Day 3, and the postoperative course was uneventful. CONCLUSIONS: R-SPDP can be a good option for post-DG patients to preserve the remnant stomach safely.

Delayed Gastric Emptying and Gastric Remnant Function After Pancreaticoduodenectomy: A Systematic Review of Objective Assessment Modalities.

BACKGROUND: Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD). The diagnosis of DGE is based on International Study Group for Pancreatic Surgery (ISGPS) clinical criteria and objective assessments of DGE are infrequently used. The present literature review aimed to identify objective measures of DGE following PD and determine whether these measures correlate with the clinical definition of DGE. METHODS: A systematic search was performed using the MEDLINE Ovid, EMBASE, Google Scholar and CINAHL databases for studies including pancreatic surgery, delayed gastric emptying and gastric motility until June 2022. The primary outcome was modalities undertaken for the objective measurement of DGE following PD and correlation between objective measurements and clinical diagnosis of DGE. Relevant risk of bias analysis was performed. RESULTS: The search revealed 4881 records, of which 46 studies were included in the final analysis. There were four objective modalities of DGE assessment including gastric scintigraphy (n = 28), acetaminophen/paracetamol absorption test (n = 10), fluoroscopy (n = 6) and the 13C-acetate breath test (n = 3). Protocols were inconsistent, and reported correlations between clinical and objective measures of DGE were variable; however, amongst these measures, at least one study directly or indirectly inferred a correlation, with the greatest evidence accumulated for gastric scintigraphy. CONCLUSION: Several objective modalities to assess DGE following PD have been identified and evaluated, however are infrequently used. Substantial variability exists in the literature regarding indications and interpretation of these tests, and there is a need for a real-time objective modality which correlates with ISGPS DGE definition after PD.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy.

PURPOSE: This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively. METHODS: We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5). RESULTS: Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups. CONCLUSIONS: L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

A rare complication of laparoscopic Roux-en-Y gastric bypass: case report of gastric remnant necrosis.

Gastric remnant necrosis is a very rare, but potential life-threatening complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). We report a case of gastric remnant necrosis that was complicated by peritonitis and resulted in septic shock in a 49-year-old woman who had undergone a LRYGB three months prior to admission. An emergent laparoscopy with subtotal gastrectomy was performed. The patient was treated for septic shock and could leave the hospital in a good condition. Potential etiological factors for gastric remnant necrosis were elaborated.

[Two Cases of Closed LECS for Early Gastric Cancer].

In recent years, laparoscopy and endoscopy cooperative surgery(LECS)is reported as the treatment of gastric cancer. We report closed LECS performed for an elderly patient with remnant gastric cancer and gastric cancer in a patient with lung cancer. Case 1 is an 85-year-old male. Early gastric cancer was pointed out in the remnant stomach after distal gastrectomy. ESD was not indicated because of the size of tumor. Because of his age and many comorbidities, closed LECS was performed. Postoperative pathological diagnosis was pT1a(M), pPM0, pDM0, Ly0, v0. Case 2 is a 56-year-old male. He was undergoing chemotherapy for lung cancer with pleural dissemination. Upper gastrointestinal endoscopy revealed early gastric cancer. ESD was not indicated for this lesion because of the depth of tumor. Pleural dissemination of lung cancer is his prognostic factor, and gastrectomy with lymph node dissection was considered excessively invasive. Therefore, closed LECS was performed. Postoperative pathological diagnosis was pT1b2(SM2), pPM0, pDM0, Ly1c, v1a. Closed LECS could be useful therapeutic option for early gastric cancer.

Safety and efficacy of double-tract reconstruction with remnant stomach conservation in esophagectomy for patients with a history of distal gastrectomy.

BACKGROUND: Total gastrectomy with jejunum or colon reconstruction after esophagectomy is commonly performed in patients with esophageal cancer who have a history of distal gastrectomy. In this study, we examined the safety and effectiveness of double-tract reconstruction (DTR) with preservation of the remnant stomach for said patient population. METHODS: Twenty-seven esophageal cancer patients with a history of distal gastrectomy who underwent transthoracic esophagectomy between 2010 and 2020 in our institution were retrospectively analyzed; 15 of these patients underwent DTR, whereas 12 underwent completion gastrectomy with jejunal Roux-en-Y reconstruction (RYR). Short-term outcomes, postoperative nutritional indexes, and ghrelin levels were evaluated. Moreover, abdominal lymph-node metastasis and recurrence, which were removed by total residual gastrectomy, were examined to determine the oncological validity of residual stomach preservation. RESULTS: There was no metastasis and recurrence in abdominal lymph nodes, such as #4sa or #11d, which were removed by total residual gastrectomy. Total operation time did not differ between the groups (P = 0.4247). The blood loss for the DTR group was 495 ± 446 mL, whereas that for the RYR group was 844 ± 575 mL (P = 0.0168). Clavien-Dindo grade III or higher complications were not significantly different between the groups (P = 0.7063). The rates of serum total protein values at 6 months in the DTR and RYR groups were 112% ± 12.2% and 102.6% ± 10.7% (P = 0.0403), respectively. The prognostic nutritional indexes at 6 months in the DTR and RYR groups were 108.6% ± 14.5% and 83.2% ± 42.6% (P = 0.0376), respectively. CONCLUSIONS: DTR in esophagectomy is safe and effective for patients with a history of distal gastrectomy.

A Modified Billroth-II with Braun Anastomosis in Totally Laparoscopic Distal Gastrectomy: Initial Experience Compared with Roux-en-Y Anastomosis.

BACKGROUND: This retrospective study aimed to compare the feasibility and effectiveness of a modified Billroth-II with Braun (B-II Braun) reconstruction and those of a Roux-en-Y (R-Y) reconstruction after laparoscopic distal gastrectomy. METHODS: From January 2016 to December 2019, 247 patients underwent total laparoscopic distal gastrectomy (TLDG), with B-II Braun reconstruction for 145 patients and R-Y reconstruction for 102 patients. The patients' data were collected prospectively and reviewed retrospectively. RESULTS: In this study, the median times of the operation were statistically shorter for B-II Braun than for R-Y (167 min [range, 110-331 min] vs 191 min [range, 123-384 min]; p = 0.001), including anastomotic times (33 min [range, 30-42 min] vs 42 min [range, 40-48 min]; p = 0.001). After a short-term follow-up period, endoscopy showed 31 cases of bile reflux (21.4%), 15 cases of grade 2 gastritis (10.3%), and 6 cases of grade 2 food residue (4.1%) in the B-II Braun group after 6 months. After 1 year, 10 patients (6.9%) had grade 2 gastritis and 2 patients (1.4%) had grade 3 gastritis. However, the remnant stomach of the two groups did not differ significantly in the rate of gastric residue (p = 0.112 after 6 months; p = 0.579 after 1 year, respectively), gastritis (p = 0.726 after 6 months; p = 0.261 after 1 year, respectively), or bile reflux (p = 0.262 after 6 months; p = 0.349 after 1 year, respectively). CONCLUSIONS: For gastric cancer patients, TLDG with modified B-II Braun reconstruction could be technically feasible. It has an acceptable range of postoperative complications and is effective in preventing bile reflux into the gastric remnant.

Minimum resection length to ensure a pathologically negative distal margin and the preservation of a larger remnant stomach in proximal gastrectomy for early upper gastric cancer.

BACKGROUND: In proximal gastrectomy (PG), a longer distal margin (DM) length should be maintained to obtain a pathologically negative DM. However, a shorter DM length is preferred to preserve a large remnant stomach for favorable postoperative outcomes. Evidence regarding the minimum DM length to ensure a pathologically negative DM is useful. METHODS: Patients who underwent PG or total gastrectomy for cT1N0M0 gastric cancer limited to the upper third were enrolled. A new parameter, ΔDM, which corresponded to the pathological extension distal to the gross tumor boundary towards the resection stump, was evaluated. The maximum ΔDM, which is the length ensuring a pathologically negative DM, was first determined. Furthermore, the possible incidences of pathologically positive DM were calculated for each pathological type and clinical tumor (cTumor) size. RESULTS: Of 361 patients eligible for this study, 190 and 171 were assigned to differentiated (Dif) and undifferentiated types (Und), respectively. The maximum ΔDM was 30 and 40 mm in Dif and Und, respectively. Considering a correlation between cTumor size and ΔDM, and possible incidences of pathologically positive DM, 10, 20, and 30 mm were the minimal gross DM lengths in Dif when cTumor size was ≤ 15 mm, > 15 and ≤ 50 mm, and > 50 mm, respectively. In Und, the incidences of pathologically positive DM were 0.59% and 2.3% for gross DM lengths of 30 and 20 mm, respectively. CONCLUSION: The minimum DM lengths to ensure a pathologically negative DM in PG are proposed according to the pathological type of early upper gastric cancer.

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.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition.

BACKGROUND: This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction. METHODS: Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes. RESULTS: Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030). CONCLUSIONS: Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

[A Case of Completion Gastrectomy for Metachronous Gastric Cancer in the Remnant Stomach after Successful Treatment with ESD].

A 73-year-old man underwent distal gastrectomy, D2 lymphadenectomy, and Billroth Ⅰ reconstruction for Type 3 advanced cancer in the lower corpus lesser curvature in 20XX. After postoperative adjuvant chemotherapy, he self-detected a mass in the left breast. It was diagnosed as breast cancer. He underwent mastectomy and axillary lymphadenectomy 16 months after gastric cancer surgery. After postoperative adjuvant chemotherapy, gastric or breast cancer did not recur. However, periodic upper gastrointestinal endoscopy revealed an 8-mm 0-Ⅱa lesion in the anterior wall of the remnant middle stomach(Group 5)80 months after gastric cancer surgery. Endoscopic submucosal dissection(ESD)was performed, and radical resection was achieved. Periodic upper gastrointestinal endoscopy was performed thereafter; an ectopic 0-Ⅱa lesion was detected in the greater curvature of the remnant middle stomach(Group 5)21 months after ESD. Since this lesion suggested massive submucosal invasion, total resection of the remnant stomach and Roux-en-Y reconstruction were performed. The postoperative course has been favorable, and the patient has been alive without recurrence for 6 months postoperatively. A long period passes before intestinal juice reflux induces progression of a chronic inflammatory gastric mucosal lesion to cancer in the remnant stomach. Thus, long-term endoscopic follow-up may be necessary.

[A Case of Gastric Granular Cell Tumor Resected by a Surgical Robot].

A 46-year-old man was referred to further treatment for a 20 mm submucosal tumor at the gastric angle found during a medical check-up. Endoscopic ultrasonography and chest abdominal contrast-enhanced CT revealed the tumor was located at the 4th(proper muscular)layer of the posterior wall of the gastric antrum and slightly enhanced. No metastasis was found. Although a biopsy failed to reveal an accurate diagnosis, GIST was clinically suspected. A robotic distal gastrectomy was planned to manage the residual gastric stricture. The intraoperative findings indicated possible passage of the remnant stomach; therefore, local resection was performed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 9. A histopathological examination confirmed the diagnosis of a PAS-positive, S100-positive granular cell tumor with no nuclear atypia. These findings suggest that use of the robotic approach could help determine the stomach resection extent.

The incidences of metachronous multiple gastric cancer after various types of gastrectomy: analysis of data from a nationwide Japanese survey.

BACKGROUND: The incidence of metachronous multiple gastric cancer (MMGC) after gastrectomy remains unclear. This study evaluated the incidences of MMGC according to specific gastrectomy types, including pylorus-preserving gastrectomy (PPG), proximal gastrectomy (PG), and function-preserving gastrectomy (FPG), which was categorized as segmental gastrectomy and local resection. METHODS: We conducted a questionnaire survey of the Japanese Society for Gastro-Surgical Pathophysiology members, who were asked to report their institutional numbers of radical gastrectomy cases for cancer between 2003 and 2012. The cases were categorized according to whether the remnant stomach's status was followed for > 5 years, confirmation of MMGC, time to diagnosis, and treatment for MMGC. We calculated the "precise incidence" of MMGC by dividing the number of MMGC cases by the number of cases in which the status of remnant stomach was followed up for > 5 years. RESULTS: The responses identified 33,731 cases of gastrectomy. The precise incidences of MMGC were 2.35% after distal gastrectomy (DG), 3.01% after PPG, 6.28% after PG (p < 0.001), and 8.21% after FPG (p < 0.001). A substantial proportion of MMGCs (36.4%) was found at 5 years after the initial surgery. The rates of MMGC treatment using endoscopic submucosal dissection were 31% after DG, 28.6% after PPG, 50.8% after PG (p < 0.001), and 67.9% after FPG (p < 0.001). CONCLUSIONS: The incidence of MMGC was 2.4% after DG, and higher incidences were observed for larger stomach remnants. However, the proportion of cases in which MMGC could be treated using endoscopic submucosal dissection was significantly higher after PG and FPG than after DG.

Assessment of a novel stapler performance for laparoscopic sleeve gastrectomy.

BACKGROUND: Optimal stapler selection during laparoscopic sleeve gastrectomy requires careful balance between tissue compression, hemostasis, and mechanical integrity. Junctions along a staple line can further increase the risks of technical or mechanical staple line failures. The aim of this study was to compare two commonly utilized laparoscopic linear gastrointestinal staplers (Ethicon, Medtronic) with a novel linear stapler (Titan) designed to perform a sleeve gastrectomy with a single stapler firing. METHODS: Excised gastric remnants from laparoscopic sleeve gastrectomy were utilized and tissue thickness was measured from fundus to antrum. An optimized experimental staple line was then created. The greater curve remnant was insufflated to determine the staple line burst pressure and location. The doubly stapled (clinical and experimental) gastric specimen underwent staple analysis for junctional location, malformation, and height. RESULTS: The Titan stapler withstood a significantly higher burst pressure than both Ethicon and Medtronic linear cutting staplers. While the Medtronic and Ethicon staplers had a similar percentage of staples in junctions, the Titan stapler has no junctions. In considering the formation of all staples outside of junctions, the Medtronic and Titan staplers had no difference in percentage of malformed staples, while the Ethicon stapler had a significantly higher percentage. Additionally, there were no differences in mismatch between staple height and tissue thickness between experimental groups. CONCLUSIONS: The Titan stapler conveys the mechanical benefits of higher burst pressure with the advantage of single load functionality. This single staple load eliminates staple line junctions without sacrificing the integrity of staple formation.

Reconstruction of the esophagus of patients with middle thoracic esophageal carcinoma using the remnant stomach following Billroth II gastrectomy.

It seems impossible to reconstruct the esophagus of patients with middle thoracic esophageal carcinoma with a history of distal gastrectomy using the remnant stomach. Although surgeons have made multiple efforts to reconstruct the esophagus using the remnant stomach, it can only be successfully used in cases of lower thoracic esophageal cancer. Additionally, the surgery is more complex than traditional esophagogastrostomy due to challenges including mobilization of the remnant stomach with the spleen and transposition of the pancreatic tail into the left hemithorax. Our operation proved that the remnant stomach, which we named as the completely mobilized remnant stomach after dissection of the feeding vessels, remained viable. We successfully integrated the completely mobilized remnant stomach in the reconstruction of the lower thoracic esophageal tract and then integrated it in Ivor Lewis esophagogastrostomy. We describe this new alternative surgical technique for the treatment of middle thoracic esophageal carcinoma in patients with a history of distal gastrectomy in this study. Clinical data of 23 patients from 2008 to 2019 were retrospectively analyzed. All patients underwent the Ivor Lewis procedure. All remaining vessels of the remnant stomach were dissected at their origins, and Roux-en-Y reconstruction or Braun anastomosis was performed. After esophagectomy during right thoracotomy, anastomosis of the remnant stomach and esophagus was performed. Two-field lymph node dissections were performed. There was no case of necrosis of the remnant stomach or of perioperative death. Serious complications included anastomotic leak in three cases, afferent-efferent loop syndrome in one, and anastomotic stricture in two. Application of the completely mobilized remnant stomach in Ivor Lewis esophagogastrostomy is feasible, and the surgical procedure is similar to that of normal esophagogastrostomy.

T stage and venous invasion are crucial prognostic factors for long-term survival of patients with remnant gastric cancer: a cohort study.

BACKGROUND: The incidence of remnant gastric cancer (RGC) after distal gastrectomy is 1-5%. However, as the survival rate of patients with gastric cancer improves due to early detection and treatment, more patients may develop RGC. There is no consensus on the surgical and postoperative management of RGC, and the clinicopathological characteristics correlated with the long-term outcomes remain unclear. Therefore, we investigated the clinicopathological factors associated with the long-term outcomes of RGC. METHODS: We included 65 consecutive patients who underwent gastrectomy for RGC from January 2000 to December 2015 at the Osaka Medical and Pharmaceutical University Hospital, Japan. The Kaplan-Meier method was used to create survival curves, and differences in survival were compared between the groups (clinical factors, pathological factors, and surgical factors) using the log-rank test. Multivariate analyses using the Cox proportional hazard model were used to identify factors associated with long-term survival. RESULTS: No significant differences were noted in the survival rate based on clinical factors (age, body mass index, diabetes mellitus, hypertension, cardiovascular disease, pulmonary complications, liver disease, diet, history of alcohol drinking, and history of smoking) or the type of remnant gastrectomy. Significant differences were noted in the survival rate based on pathological factors and surgical characteristics (intraoperative blood loss, operation time, and the number of positive lymph nodes). Multivariate analysis revealed that the T stage (hazard ratio, 5.593; 95% confidence interval [CI], 1.183-26.452; p = 0.030) and venous invasion (hazard ratio, 3.351; 95% CI, 1.030-10.903; p = 0.045) were significant independent risk factors for long-term survival in patients who underwent radical resection for RGC. CONCLUSIONS: T stage and venous invasion are important prognostic factors of long-term survival after remnant gastrectomy for RGC and may be keys to managing and identifying therapeutic strategies for improving prognosis in RGC.