Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: Results of a randomised clinical trial

AbstractBackgroundThe optimal anti-reflux procedure after Heller cardiomyotomy for oesophageal achalasia remains unclear. The most commonly used procedure is the anterior partial fundoplication according to Dor, although during recent years the posterior counterpart (Toupet) has become popular.MethodsPatients with newly diagnosed achalasia and referred for cardiomyotomy were randomised to receive either an anterior or partial posterior fundoplication following a classical cardiomyotomy. The effect of surgery was assessed during the first postoperative year by Eckardt scores, EORTC QLQ-OES18 scores and HRQL questionnaires. Timed barium oesophagogram (TBO) and ambulatory 24-h pH monitoring were performed to determine oesophageal emptying and the degree of reflux control, respectively.ResultsForty-two patients were randomised into Dor (n = 20) and Toupet (n = 22) groups. Eckardt scores improved dramatically with both procedures, but the EORTC QLQ-OES18 (functional scales) scores revealed significantly better relative improvements in the Toupet group compared to the Dor repair (P = 0.044). Corresponding advantages in favour of Toupet were observed postoperatively in the percentage of oesophageal emptying at TBO (P = 0.011 in height and P = 0.018 in area), an effect not observed in the Dor group. There were no other significant differences recorded between the study groups concerning HRQL evaluations and objective assessment of gastro-oesophageal acid reflux.ConclusionsA partial posterior fundoplication after cardiomyotomy seems to achieve more improvement in oesophageal emptying and EORTC QLQ-OES18 functional scale scores than the anterior fundoplication. Otherwise no differences between the two anti-reflux repairs were noted.Trial registration numberClinicalTrials.gov Identifier: NCT01933373

Impact of obesity on the outcomes after gastrectomy for gastric cancer: A meta-analysis.

Summary: The impact of body mass index (BMI) on surgical outcomes has previously been studied in relation to several oncological procedures. Regarding gastric cancer surgery, published results have been contradicting in terms of degree of technical difficulty, risk of postoperative complications and survival. In an attempt to clarify these issues, we performed a meta-analysis to evaluate the impact of obesity (defined as BMI ≥ 30 kg/m2) on outcomes after gastrectomy for gastric cancer. The meta-analysis was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, EMBASE, Web of Science and Cochrane Library databases. Quality assessment was performed using the Newcastle-Ottawa scale. The meta-analysis was conducted using random-effects modeling. A total of 11 studies with 13 538 patients were eligible for analysis. Obesity was associated with a significantly longer operation time (WMD = 19.38 min, 95% CI 12.72–26.04; p < 0.001), increased risk of overall complications (RR = 1.23, 95% CI 1.06–1.42; p = 0.005) and pulmonary complications (RR = 3.81, 95% CI 2.24–6.46; p < 0.001). These findings remained irrespective type of surgery (laparoscopic vs. open) and type of gastrectomy. No differences were found regarding blood loss, number of resected lymph nodes, anastomotic leakage, hospital stay, 30-day mortality and 5-year overall survival. The conclusion of the current meta-analysis is that high BMI in gastric cancer patients is associated with longer operative time and more frequent overall postoperative complications. However, it has no negative impact on survival, indicating that gastrectomy is a safe procedure for this group of patients

Impact of obesity on the outcomes after gastrectomy for gastric cancer: A meta-analysis

The impact of body mass index (BMI) on surgical outcomes has previously been studied in relation to several oncological procedures. Regarding gastric cancer surgery, published results have been contradicting in terms of degree of technical difficulty, risk of postoperative complications and survival. In an attempt to clarify these issues, we performed a meta-analysis to evaluate the impact of obesity (defined as BMI &gt;= 30 kg/m(2)) on outcomes after gastrectomy for gastric cancer. The meta-analysis was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, EMBASE, Web of Science and Cochrane Library databases. Quality assessment was performed using the Newcastle-Ottawa scale. The meta-analysis was conducted using random-effects modeling. A total of 11 studies with 13 538 patients were eligible for analysis. Obesity was associated with a significantly longer operation time (WMD = 19.38 min, 95% CI 12.72-26.04; p &lt; 0.001), increased risk of overall complications (RR = 1.23, 95% CI 1.06-1.42; p = 0.005) and pulmonary complications (RR = 3.81, 95% CI 2.24-6.46; p &lt; 0.001). These findings remained irrespective type of surgery (laparoscopic vs. open) and type of gastrectomy. No differences were found regarding blood loss, number of resected lymph nodes, anastomotic leakage, hospital stay, 30-day mortality and 5-year overall survival. The conclusion of the current meta-analysis is that high BMI in gastric cancer patients is associated with longer operative time and more frequent overall postoperative complications. However, it has no negative impact on survival, indicating that gastrectomy is a safe procedure for this group of patients. (C) 2021 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V

Minimum Esophageal Resection Length to Ensure Negative Proximal Margin in Total Gastrectomy for Gastric Cancer

Objective:. To identify the minimum length of esophageal resection to ensure a pathologically negative proximal margin (PM) in total gastrectomy for gastric cancer. Background:. In total gastrectomy, a certain esophageal length is resected to obtain a pathologically negative PM because of the possibility of unexpected pathological esophageal invasion. However, a recommendation regarding the esophageal transection site in total gastrectomy has not been established. Methods:. The data of patients who underwent total gastrectomy for gastric cancer from 2005 to 2018 were collected. We evaluated the length of unexpected pathological esophageal invasion (esophageal ΔPM) in each type of disease and each location of the gross proximal tumor boundary (PB) using the length between the PB and the esophagogastric junction (PB-EGJ length). Results:. Of the 1005 patients eligible for this study, 277, 196, and 532 had cT1, cT2–4 expansive (Exp), and cT2–4 infiltrative (Inf) growth patterns, respectively. In cT1 and Exp, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >1 cm, whereas pathological esophageal invasion occurred in 20.0% of cT1 and 32.7% of Exp when the PB-EGJ length was ≤1 cm. The esophageal ΔPM was 3 cm, whereas pathological esophageal invasion occurred in 17.4% of patients when the PB-EGJ length was ≤3 cm. The esophageal ΔPM was <2 cm. Conclusions:. New recommendations regarding the esophageal resection length required to ensure a pathologically negative PM in total gastrectomy are herein proposed

Oncological Impact of Gross Proximal Margin Length in Distal Gastrectomy for Gastric Cancer: Is the Japanese Recommendation Valid?

Objective:. To identify an oncological impact of gross proximal margin (PM) length in distal gastrectomy for cancer. Summary background data:. In Japan, to obtain pathologically negative PMs in gastrectomy for cancer, the Gastric Cancer Treatment Guidelines (GCTGs) recommend maintaining the PM length to at least 2 cm for cT1, 3 cm for the expansive growth type (Exp), and 5 cm for the infiltrative growth type (Inf) of cT2–4. The GCTGs also recommend confirming pathologically negative PMs by intraoperative frozen section analyses when the gross PMs are shorter than the recommendations. However, whether they are valid is unknown. Methods:. Patients who intended to undergo curative distal gastrectomy were included. They were divided into groups A (adherence to the GCTGs) and NA (nonadherence) according to the PM length. The incidence of pathologically positive PMs and survival outcomes were compared between the groups. Propensity scores (PSs) were used in comparisons of survival outcomes to eliminate potential confounders. Results:. A total of 1036 patients were eligible. Pathologically positive PMs were identified in group NA with cT1 and Inf, and the incidence was 1.6% and 3.1%, respectively. Adjusted analysis using the PSs showed comparable survival outcomes between the groups. However, the hazard ratios according to the PSs presented a possible survival advantage in maintaining the recommended gross PM lengths except for cT1 and Exp located in the lower stomach. Conclusion:. Surgeons should maintain the gross PM lengths recommended in the GCTGs to both obtain pathologically negative PMs and avoid survival disadvantages

Development of Magnetocardiograph without Magnetically Shielded Room Using High-Detectivity TMR Sensors

A magnetocardiograph that enables the clear observation of heart magnetic field mappings without magnetically shielded rooms at room temperatures has been successfully manufactured. Compared to widespread electrocardiographs, magnetocardiographs commonly have a higher spatial resolution, which is expected to lead to early diagnoses of ischemic heart disease and high diagnostic accuracy of ventricular arrhythmia, which involves the risk of sudden death. However, as the conventional superconducting quantum interference device (SQUID) magnetocardiographs require large magnetically shielded rooms and huge running costs to cool the SQUID sensors, magnetocardiography is still unfamiliar technology. Here, in order to achieve the heart field detectivity of 1.0 pT without magnetically shielded rooms and enough magnetocardiography accuracy, we aimed to improve the detectivity of tunneling magnetoresistance (TMR) sensors and to decrease the environmental and sensor noises with a mathematical algorithm. The magnetic detectivity of the TMR sensors was confirmed to be 14.1 pTrms on average in the frequency band between 0.2 and 100 Hz in uncooled states, thanks to the original multilayer structure and the innovative pattern of free layers. By constructing a sensor array using 288 TMR sensors and applying the mathematical magnetic shield technology of signal space separation (SSS), we confirmed that SSS reduces the environmental magnetic noise by −73 dB, which overtakes the general triple magnetically shielded rooms. Moreover, applying digital processing that combined the signal average of heart magnetic fields for one minute and the projection operation, we succeeded in reducing the sensor noise by about −23 dB. The heart magnetic field resolution measured on a subject in a laboratory in an office building was 0.99 pTrms and obtained magnetocardiograms and current arrow maps as clear as the SQUID magnetocardiograph does in the QRS and ST segments. Upon utilizing its superior spatial resolution, this magnetocardiograph has the potential to be an important tool for the early diagnosis of ischemic heart disease and the risk management of sudden death triggered by ventricular arrhythmia