Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.
Anastomosis, Roux-en-Y ; adverse effects ; China ; Chylous Ascites ; etiology ; prevention & control ; therapy ; Duodenum ; blood supply ; surgery ; Gastrectomy ; adverse effects ; methods ; mortality ; Gastric Outlet Obstruction ; etiology ; prevention & control ; Gastric Stump ; surgery ; Hemostatic Techniques ; Hernia ; etiology ; prevention & control ; therapy ; High-Intensity Focused Ultrasound Ablation ; instrumentation ; Humans ; Jejunum ; blood supply ; surgery ; Lymph Node Excision ; adverse effects ; instrumentation ; Lymphatic System ; injuries ; Postoperative Complications ; classification ; diagnosis ; mortality ; prevention & control ; Prognosis ; Stomach ; surgery ; Stomach Neoplasms ; complications ; surgery ; Suture Techniques ; standards ; Thoracic Duct ; injuries ; Wound Closure Techniques ; standards

With the rapid advancement of minimally invasive new technology, laparoscopic surgery and robotic surgery are now regarded as the main direction in surgical treatment for stomach cancers. Recent evidence has confirmed the safety and feasibility of laparoscopic surgery for early gastric cancer and advanced gastric cancer. However, gastrointestinal surgeons should pay more attention to complications after laparoscopic gastrectomy because of rich blood supply, complex tissue layers and lymph node metastasis. Common complications related to laparoscopic surgery are associated with laparoscopic instruments and operating, intra-abdominal bleeding, anastomotic leakage, anastomotic bleeding, pancreatic leakage, duodenal stump leakage, lymphatic leakage and so on. This article mainly focuses on the causes, prevention and treatment of the complications after laparoscopic gastrectomy.
Anastomotic Leak ; Duodenal Diseases ; Female ; Gastrectomy ; adverse effects ; instrumentation ; methods ; Humans ; Laparoscopy ; adverse effects ; instrumentation ; methods ; Lymphatic Metastasis ; Male ; Postoperative Complications ; etiology ; prevention & control ; therapy ; Robotic Surgical Procedures ; adverse effects ; instrumentation ; methods ; Stomach Neoplasms ; complications ; surgery

BACKGROUND/AIMS: Although intravenous proton pump inhibitor (PPI) has been used for the prevention of post endoscopic submucosal dissection (ESD) bleeding, the route of administration has not been confirmed. The aim of the present study was to compare the efficacy of intravenous and oral PPI administration for the prevention of delayed post ESD bleeding. METHODS: Total 166 consecutive patients were randomly assigned to 30 mg lansoprazol twice a day (PO group) and 120 mg pantoprazole intravenous injection (IV group) for 48 hours. Finally, 65 patients in PO group and 87 patients in IV group were analyzed. After ESD, all patients underwent follow up endoscopy after 24 hours and were observed the symptoms of bleeding up to 60 days after ESD. RESULTS: Age, sex and use of anticoagulants were not different between groups. At follow up endoscopy after 24 hours, oozing and exposed vessel was noted in 4.6% of PO group and 8.0% of IV group and there was no significant difference. Delayed bleeding occurred in 4 of 65 patients (6.2%) in the PO group and 8 of 87 patients (9.2%) in the IV group (p>0.999). By multivariate analysis, oozing or exposed vessels at follow up endoscopy were risk factors for delayed bleeding (OR=17.5, p=0.022). CONCLUSIONS: There was no significant difference in the delayed bleeding, length of hospital stay according to the administration route. Bleeding stigmata at follow up endoscopy was risk factor of delayed bleeding. Oral PPI administration can cost-effectively replace IV PPI for prevention of post ESD bleeding.
2-Pyridinylmethylsulfinylbenzimidazoles/therapeutic use ; *Administration, Oral ; Aged ; Anticoagulants/therapeutic use ; Endoscopic Mucosal Resection/*adverse effects ; Female ; Gastroscopy ; Humans ; *Injections, Intravenous ; Lansoprazole/therapeutic use ; Male ; Middle Aged ; Odds Ratio ; Postoperative Hemorrhage/etiology/*prevention & control ; Prospective Studies ; Proton Pump Inhibitors/*therapeutic use ; Risk Factors ; Stomach Neoplasms/surgery

Gastric cancer is associated with high morbidity and mortality worldwide. To reduce the socioeconomic burden related to gastric cancer, it is very important to identify and manage high risk group for gastric cancer. In this review, we describe the general risk factors for gastric cancer and define high risk group for gastric cancer. We discuss strategies for the effective management of patients for the prevention and early detection of gastric cancer. Atrophic gastritis (AG) and intestinal metaplasia (IM) are the most significant risk factors for gastric cancer. Therefore, the accurate selection of individuals with AG and IM may be a key strategy for the prevention and/or early detection of gastric cancer. Although endoscopic evaluation using enhanced technologies such as narrow band imaging-magnification, the serum pepsinogen test, Helicobacter pylori serology, and trefoil factor 3 have been evaluated, a gold standard method to accurately select individuals with AG and IM has not emerged. In terms of managing patients at high risk of gastric cancer, it remains uncertain whether H. pylori eradication reverses and/or prevents the progression of AG and IM. Although endoscopic surveillance in high risk patients is expected to be beneficial, further prospective studies in large populations are needed to determine the optimal surveillance interval.
Gastroscopy ; Helicobacter Infections/complications/diagnosis ; Humans ; Risk Factors ; Socioeconomic Factors ; Stomach Neoplasms/*diagnosis/etiology/prevention & control/therapy

As a commensal or a pathogen, Helicobacter pylori can change the balance of a complex interaction that exists among gastric epithelial cells, microbes, and their environment. Therefore, unraveling this complex relationship of these mixtures can be expected to help prevent cancer as well as troublesome unmet medical needs of H. pylori infection. Though gastric carcinogenesis is a multi-step process, precancerous lesion can be reversible in the early phase of mucosal damage before reaching the stage of no return. However, biomarkers to predict rejuvenation of precancerous atrophic gastritis have not been identified yet and gastric cancer prevention is still regarded as an impregnable fortress. However, when we take the journey from H. pylori-associated gastritis to gastric cancer, it provides us with the clue for prevention since there are two main preventive strategies: eradication and anti-inflammation. The evidence supporting the former strategy is now ongoing in Japan through a nation-wide effort to eradicate H. pylori in patients with chronic gastritis, but suboptimal apprehension to increasing H. pylori resistance to antibiotics and patient non-compliance still exists. The latter strategy has been continued in the author's research center under siTRP (short-term intervention to revert premalignant lesion) strategy. By focusing on the role of inflammation in the development of H. pylori-associated gastric carcinogenesis, this review is intended to explain the connection between inflammation and gastric cancer. Strategies on H. pylori eradication, removal of inflammation, and reverting preneoplastic lesion will also be introduced. In the end, we expect to be able to prevent gastric cancer by take a detour from the unpleasant journey, i.e. from H. pylori-associated gastritis to gastric cancer.
Animals ; Anti-Bacterial Agents/pharmacology/therapeutic use ; Biomarkers/metabolism ; Disease Models, Animal ; Gastritis/*etiology ; Helicobacter Infections/*complications/drug therapy ; Helicobacter pylori/drug effects/metabolism/physiology ; Humans ; Stomach Neoplasms/etiology/*prevention & control ; Virulence Factors/metabolism

BACKGROUND/AIMS: This stuy evaluated the role of a second-look endoscopy after gastric endoscopic submucosal dissection in patients without signs of bleeding. METHODS: Between March 2011 and March 2012, 407 patients with gastric neoplasms who underwent endoscopic submucosal dissection for 445 lesions were retrospectively reviewed. After the patients had undergone endoscopic submucosal dissection, they were allocated to two groups (with or without second-look endoscopy) according to the following endoscopy. The postoperative bleeding risk of the lesions was not considered when allocating the patients. RESULTS: The delayed postoperative bleeding rates did not differ between the two groups (with vs without second-look endoscopy, 3.0% vs 2.1%; p=0.546). However, a tumor in the upper-third of the stomach (odds ratio [OR], 5.353; 95% confidence interval [CI], 1.075 to 26.650) and specimen size greater than 40 mm (OR, 4.794; 95% CI, 1.307 to 17.588) were both independent risk factors for delayed postoperative bleeding. Additionally, second-look endoscopy was not related to reduced delayed postoperative bleeding. However, delayed postoperative bleeding in the patients who did not undergo a second-look endoscopy occurred significantly earlier than that in patients who underwent a second-look endoscopy (4.5 and 14.0 days, respectively, p=0.022). CONCLUSIONS: A routine second-look endoscopy after gastric endoscopic submucosal dissection is not necessary for all patients.
Female ; Gastrectomy/*adverse effects ; Gastric Mucosa/surgery ; *Gastroscopy ; Humans ; Male ; Middle Aged ; Postoperative Hemorrhage/diagnosis/etiology/*prevention & control ; Retrospective Studies ; Risk Factors ; Second-Look Surgery ; Stomach/pathology/surgery ; Stomach Neoplasms/pathology/surgery ; Time Factors

OBJECTIVETo evaluate safety and efficacy of preoperative administration of enteral nutrition support in gastric cancer patients at risk of malnutrition.

METHODSA single center randomized controlled clinical trial was performed in 60 gastric cancer patients in West China Hospital from May to October 2012. Thirty patients were given enteral nutrition support(Ensure(R)) manufactured by Abbott Laboratories for ten consecutive days before surgical operation in the treatment group, and 30 patients were given an isocaloric and isonitrogenous homogenized diet in the control group for 10 days as well. The laboratory parameters of nutritional status and hepatorenal function were observed and compared between the two groups on admission, preoperative day 1 and postoperative day 3, respectively. Clinical observations, such as nausea and vomiting, were carried out until patients were discharged.

RESULTSBefore the intervention, there were no significant differences in the baseline characteristics between the two groups. The levels of serum albumin [(33.9±5.6) g/L vs. (31.0±5.3) g/L, P<0.05], and hemoglobin[(103.4±7.7) g/L vs.(96.6±10.5) g/L, P<0.01] were significantly improved in the treatment group on postoperative day 3. However, the levels of body mass index, lymphocyte count, liver and renal function, serum glucose, sodium, and potassium were not significantly different between the two groups(all P>0.05). Moreover, two patients with nausea and one with vomiting in each group were found. In clinical observation period, no severe treatment-related adverse event were observed.

CONCLUSIONThe enteral supplement with Ensure(R) in gastric cancer patients at risk of malnutrition during preoperative period is effective and safe, which is superior to homogenized diet and an appropriate choice for gastric cancer patients with nutritional risk.

Enteral Nutrition ; Gastrectomy ; adverse effects ; Humans ; Malnutrition ; etiology ; prevention & control ; Nutritional Status ; Postoperative Period ; Preoperative Care ; methods ; Risk Factors ; Stomach Neoplasms ; surgery

OBJECTIVETo evaluate the therapeutic effects of trans-abdominal-mediastinal drainage tube on the prevention of esophagogastric or esophago-jejunal anastomotic leakage.

METHODSA total of 79 patients underwent thoraco-abdominal radical resection for gastric cardia cancer, with high risk of leakage of the anatsomosis, from Aug. 2007 to Aug. 2011 were included in this study. They were assigned into 2 groups. Forty one patients had trans-abdominal-mediastinal drainage tube (improvement group) and 38 patients were without the mediastinal drainage tube (control group). The clinical data of all the 79 patients were reviewed and the therapeutic effects of the two treatment approaches were compared.

RESULTSThere was anastomotic leakage in four patients of the improvement group. They were with stable vital signs and the median hospital stay was 29.3 days. There was anastomotic leakage in five cases of the contol group and all of them had high fever and chest tightness. One among those five patients had transdermal placement of thoracic drainage tube and was cured, and four among those five patients had second debridement operation, with 3 cured and one death case. Except the one death case, the median hospital stay of the control group was 53.4 days, significantly longer than that of the improvement group (P < 0.05).

CONCLUSIONSAlthough putting trans-abdominal-mediastinal drainage tube can not prevent the leakage of esophagogastric or esophago-jejunnal anastomosis, it can reduce the systemic inflammatory responses, death and painful suffering of the patients caused by anastomotic leakage.

Aged ; Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; etiology ; prevention & control ; Cardia ; Drainage ; methods ; Esophagus ; surgery ; Female ; Humans ; Jejunum ; surgery ; Length of Stay ; Male ; Middle Aged ; Stomach ; surgery ; Stomach Neoplasms ; surgery

OBJECTIVETo investigate the antireflux effects of a modified Nissen fundoplication following esophagectomy for cancer.

METHODSFrom March 2006 to March 2007, 70 patients with esophageal cancer were divided into two groups randomly. Esophagogastrostomy with a stapler only was perform in 35 patients as controls (group C), and a modified Nissen fundoplication was added after esophagogastrostomy with stapler in the other 35 patients as observed group (group O). There were 48 male and 22 female, ranging in age from 47 to 77 years (mean 60.1 years). The operative morbidity and mortality were recorded. Fourty-nine patients were followed at 3 months after surgery, and the questionnaire of life quality (EORTC QLQ C-30) was conducted in 24 patients in group C and 25 patients in group O. Thirty patients were examined with esophageal manometry, 24 h pH monitoring and gastroscopy. There were 16 patients in group C and 14 patients in group O.

RESULTSThere was no significant difference in postoperative morbidity between the two groups (P > 0.05). However, the scores of heart burn and regurgitation in the group O were less than in group C (P = 0.041 and 0.034 respectively), but there was no difference in scores of dysphagia between the two groups (P = 0.677). The pressure at the anastomotic site was higher than that in the stomach in group O (P = 0.032), but not in group C (P = 0.448). DeMeester score in group O was 53 ± 46, compared to 140 ± 103 in group C (P = 0.043). The score of esophagitis was 0.9 ± 0.8 in group O, which was lower than 1.6 ± 1.0 in group C (P = 0.041).

CONCLUSIONSAddition of modified Nissen fundoplication after esophagectomy and esophagogastrostomy for cancer significantly increases the pressure at the anastomotic site, thus reduces the extent of gastroesophageal reflux, which leads to the reduction of the extent of reflux esophagitis and the improvement of the quality of life.

Aged ; Anastomosis, Surgical ; methods ; Esophageal Neoplasms ; surgery ; Esophagectomy ; Esophagus ; surgery ; Female ; Follow-Up Studies ; Gastroesophageal Reflux ; etiology ; prevention & control ; Humans ; Male ; Middle Aged ; Postoperative Complications ; prevention & control ; Stomach ; surgery

OBJECTIVETo compare a side-to-side esophagogastric anastomosis with conventional hand-sewn or stapled esophagogastrostomy for prevention of anastomotic stricture by randomized clinical trial.

METHODSBetween November 2007 and September 2008, 160 patients with esophageal carcinoma or gastric cardia cancer were consecutively admitted and underwent surgical treatment. After excluding 5 patients (2 refused to participate in and 3 did not meet inclusion criteria), the remaining 155 patients were completely randomized to receive either a side-to-side esophagogastric anastomosis (SS group), or the conventional hand-sewn (HS group), or a circular stapled (CS group) anastomosis, after the removal of esophageal tumor. The primary outcome measured the incidence of anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice

RESULTSThere was 1 operative death (in HS group) and 1 simple exploration (in SS group). The anastomotic leakage was observed in 4 patients (2 cervical and 1 intrathoracic leaks in HS group, and 1 intrathoracic leak in CS group). The follow-up rate was 96.1% (1 patient in SS group, 3 in HS group, and 2 in CS group were lost). Finally 45 patients in SS group, 52 in HS group, and 47 in CS group were included in the analysis. The 3 groups were preoperative similar. The anastomotic stricture rate was 0% (0/45) in SS group, 9.6% (5/52) in HS group, and 19.1% (9/47) in CS group, respectively (Fisher exact probability test, P = 0.005). The reflux/regurgitation score among 3 groups was similar (chi(2) = 1.681, P = 0.432).

CONCLUSIONThe side-to-side esophagogastric anastomosis could prevent stricture formation, without increasing gastroesophageal reflux.

Adult ; Aged ; Aged, 80 and over ; Anastomosis, Surgical ; adverse effects ; methods ; Cardia ; Constriction, Pathologic ; etiology ; prevention & control ; Esophageal Neoplasms ; surgery ; Esophagus ; surgery ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Postoperative Complications ; prevention & control ; Stomach ; surgery ; Stomach Neoplasms ; surgery