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Early operative treatment for anastomotic leak following bariatric surgery is associated with less adverse outcomes


This single centre retrospective study evaluated the approach to suspected leakage in a high-volume bariatric surgery unit following laparoscopic Roux-en-Y gastric bypass (LRYGB). A total of 6030 patients underwent LRYGB during the study period. The leakage rate was 1·1 per cent (64 patients). Forty-five leaks (70 per cent) were treated surgically and 19 (30 per cent) conservatively. Eight (13 per cent) of 64 patients needed intensive care and the mortality rate was 3 per cent (2 of 64). Early leaks (developing in 5 days or fewer after LRYGB) were treated by suture of the defect in 20 of 22 patients and/or operative drainage in 13. Late leaks (after 5 days) were managed with operative drainage in 19 of 23 patients and insertion of a gastrostomy tube in 15. Patients who underwent surgical treatment early after the symptoms of leakage developed had a shorter hospital stay than those who had symptoms for more than 24 h before reoperation (12·5 versus 24·4 days respectively; P < 0·001).

Br J Surg. 2014 Mar;101(4):417-23. doi: 10.1002/bjs.9388.







Diabetic patients who undergo lap chole 24 h or more after admission may have worse postop outcomes


This retrospective analysis of patients undergoing laparoscopic cholecystectomy compared outcomes following acute cholecystitis in diabetic patients following early (within 24 h) vs. delayed (24 h or more) using the American College of Surgeons National Surgical Quality Improvement Program database. From a total of 2892 patients, 144 patients with diabetes were matched with 432 without diabetes by PSM. Delaying cholecystectomy for at least 24 h after admission in patients with diabetes was associated with significantly higher odds of developing surgical-site infections (adjusted odds ratio 4.11, 95 per cent confidence interval 1.11 to 15.22; P = 0.034) and a longer hospital stay. For patients with no diabetes, however, delaying cholecystectomy had no impact on complications or length of hospital stay.

Br J Surg. 2014 Jan;101(2):74-8. doi: 10.1002/bjs.9382. Epub 2013 Dec 16.







Resident involvement in lap gastric bypass is associated with wound infections and venous thromboembolism


This study analyzed 17,057 patients who underwent a primary laparoscopic gastric bypass to assess outcomes following resident involvement. Risk-adjusted 30-day complication rates with and without residents were 13.0% and 8.5%, respectively (p < 0.01). Resident involvement was independently associated with wound infection (odds ratio [OR] = 2.06; 95% CI, 1.24-3.43) and venous thromboembolism (OR = 2.01; 95% CI, 1.19-3.40), but not with any other medical or surgical complications. Operative duration was longer with resident involvement (median duration with residents 129 minutes vs 88 minutes without; p < 0.01). After adjusting for operative duration, resident involvement was still independently associated with wound infection (OR = 1.67; 95% CI, 1.01-2.76), but not venous thromboembolism (OR = 1.73; 95% CI, 0.99-3.04).

J Am Coll Surg. 2014 Feb;218(2):253-60. doi: 10.1016/j.jamcollsurg.2013.10.014. Epub 2013 Oct 29.








No difference was found in overall 5-year survival between D1 and D2 resection


The aim of this multicentre randomized trial was to compare D2 and D1 lymphadenectomy in the treatment of gastric cancer. 267 eligible patients were allocated to either D1 (133 patients) or D2 (134) resection. Morbidity (12.0 versus 17.9 per cent respectively; P = 0.183) and operative mortality (3.0 versus 2.2 per cent; P = 0.725) rates did not differ significantly between the groups. Median follow-up was 8.8 (range 4.5-13.1) years for surviving patients and 2.4 (0.2-11.9) years for those who died, and was not different in the two treatment arms. There was no difference in the overall 5-year survival rate (66.5 versus 64.2 per cent for D1 and D2 lymphadenectomy respectively; P = 0.695). Subgroup analyses showed a 5-year disease-specific survival benefit for patients with pathological tumour (pT) 1 disease in the D1 group (98 per cent versus 83 per cent for the D2 group; P = 0.015), and for patients with pT2-4 status and positive lymph nodes in the D2 group (59 per cent versus 38 per cent for the D1 group; P = 0.055).

Br J Surg. 2014 Jan;101(2):23-31. doi: 10.1002/bjs.9345.






Mortality and morbidity from perforated peptic ulcer can be reduced by adherence to perioperative strategies


This review examines the strategies to improve outcome following surgery for perforated peptic ulcer (PPU). Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

Br J Surg. 2014 Jan;101(1):e51-64. doi: 10.1002/bjs.9368. Epub 2013 Nov 29.











Lap sleeve gastrectomy or Roux-en-Y bypass are feasible options for failed or complicated lap gastric banding

The aim of this retrospective study was to compare the results of conversions of laparoscopic adjustable gastric banding (LAGB) to either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in failed LAGB using a single-stage approach. Fifty-nine patients, 11 men and 48 women, were included in the study. The most frequent indication was insufficient weight loss or weight regain (non-responders group), in 44 patients (75 per cent); 15 patients had a revision for complicated LAGB. The early complication rate in the non-responders group was 7 per cent (3 of 44 patients), compared with 13 per cent (2 of 15) in the complicated LAGB group. Mean(s.d.) %EWL in the non-responders group was 55(22) per cent in patients converted to LRYGB and 28(25) in those converted to LSG (P = 0·001).

Br J Surg. 2014 Feb;101(3):254-60. doi: 10.1002/bjs.9344.






VTE at cancer diagnosis was higher in patients with pancreaticobiliary tract rather than other forms of upper GI cancer


This study aimed to determine the prevalence of venous thromboembolism (VTE) at diagnosis of upper GI cancer. 250 patients had ultrasonography; CTPA was performed in 143 patients on admission. DVT was detected in 13 (5·2 per cent) of the 250 patients, eight (3·2 per cent) of whom were asymptomatic. DVT was correlated with tumour location in the pancreaticobiliary tract (odds ratio (OR) 6·27, 95 per cent confidence interval 1·18 to 33·38; P = 0·031) and tumour stage IV (OR 19·34, 2·33 to 160·70; P = 0·006). PE was detected in 11 (7·7 per cent) of 143 patients, eight (5·6 per cent) of whom were asymptomatic. PE embolism was also significantly more common in patients with pancreaticobiliary tract cancer (OR 7·81, 1·28 to 47·62; P = 0·026) and in those with stage IV disease (OR 17·19, 1·83 to 161·50; P = 0·013).

Br J Surg. 2014 Feb;101(3):246-53. doi: 10.1002/bjs.9353. Epub 2014 Jan 20.








No evidence of difference in mortality among overweight / #obese #diabetics and normal-weight counterparts


The relationship between body weight and mortality among persons with type 2 diabetes was investigated in the Nurses' Health Study (8970 participants) and Health Professionals Follow-up Study (2457 participants) who were free of cardiovascular disease and cancer at the time of a diagnosis of diabetes. There were 3083 deaths during a mean period of 15.8 years of follow-up. A J-shaped association was observed across BMI categories (18.5 to 22.4, 22.5 to 24.9 [reference], 25.0 to 27.4, 27.5 to 29.9, 30.0 to 34.9, and 35.0) for all-cause mortality (hazard ratio, 1.29 [95% confidence interval {CI}, 1.05 to 1.59]; 1.00; 1.12 [95% CI, 0.98 to 1.29]; 1.09 [95% CI, 0.94 to 1.26]; 1.24 [95% CI, 1.08 to 1.42]; and 1.33 [95% CI, 1.14 to 1.55], respectively). This relationship was linear among participants who had never smoked (hazard ratios across BMI categories: 1.12, 1.00, 1.16, 1.21, 1.36, and 1.56, respectively) but was nonlinear among participants who had ever smoked (hazard ratios across BMI categories: 1.32, 1.00, 1.09, 1.04, 1.14, and 1.21) (P=0.04 for interaction). A direct linear trend was observed among participants younger than 65 years of age at the time of a diabetes diagnosis but not among those 65 years of age or older at the time of diagnosis (P<0.001 for interaction).

N Engl J Med. 2014 Jan 16;370(3):233-44. doi: 10.1056/NEJMoa1304501.












Gastric acid inhibitor use is significantly associated with the presence of vitamin B12 deficiency


This investigated the association of vitamin B12 deficiency and prior use of acid-suppressing medication Proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs) using a case-control study within the Kaiser Permanente Northern California population. 25,956 patients having incident diagnoses of vitamin B12 deficiency between January 1997 and June 2011 were compared with 184,199 patients without B12 deficiency. Among patients with incident diagnoses of vitamin B12 deficiency, 3120 (12.0%) were dispensed a 2 or more years' supply of PPIs, 1087 (4.2%) were dispensed a 2 or more years' supply of H2RAs (without any PPI use), and 21,749 (83.8%) had not received prescriptions for either PPIs or H2RAs. Among patients without vitamin B12 deficiency, 13,210 (7.2%) were dispensed a 2 or more years' supply of PPIs, 5897 (3.2%) were dispensed a 2 or more years' supply of H2RAs (without any PPI use), and 165,092 (89.6%) had not received prescriptions for either PPIs or H2RAs. Both a 2 or more years' supply of PPIs (OR, 1.65 [95% CI, 1.58-1.73]) and a 2 or more years' supply of H2RAs (OR, 1.25 [95% CI, 1.17-1.34]) were associated with an increased risk for vitamin B12 deficiency. Doses more than 1.5 PPI pills/d were more strongly associated with vitamin B12 deficiency (OR, 1.95 [95% CI, 1.77-2.15]) than were doses less than 0.75 pills/d (OR, 1.63 [95% CI, 1.48-1.78]; P = .007 for interaction).

JAMA. 2013 Dec 11;310(22):2435-42. doi: 10.1001/jama.2013.280490.






20% tax on sugar sweetened drinks could lead to a reduction in prevalence of obesity in the UK


This study modelled the overall and income specific effect of a 20% tax on sugar sweetened drinks on the prevalence of overweight and obesity in the UK. A 20% tax on sugar sweetened drinks was estimated to reduce the number of obese adults in the UK by 1.3% (95% credible interval 0.8% to 1.7%) or 180,000 (110,000 to 247,000) people and the number who are overweight by 0.9% (0.6% to 1.1%) or 285,000 (201,000 to 364,000) people. The predicted reductions in prevalence of obesity for income thirds 1 (lowest income), 2, and 3 (highest income) were 1.3% (0.3% to 2.0%), 0.9% (0.1% to 1.6%), and 2.1% (1.3% to 2.9%). The effect on obesity declined with age. Predicted annual revenue was £276m (£272m to £279m), with estimated increases in total expenditure on drinks for income thirds 1, 2, and 3 of 2.1% (1.4% to 3.0%), 1.7% (1.2% to 2.2%), and 0.8% (0.4% to 1.2%).

BMJ. 2013 Oct 31;347:f6189. doi: 10.1136/bmj.f6189.









Laparoscopic adjustable gastric bands may not be a definitive solution for obesity


This study examined the fate of laparoscopic adjustable gastric bands in a single unit in the UK with over a 10 year period. Between 2000 and 2012, 674 bands were placed in 665 patients. Of these, 143 (21·2 per cent) were removed. There was no difference in rates of removal by sex (P = 0·910). The highest rates of removal were in patients aged less than 40 years (26·7 per cent), and those with a BMI greater than 60 kg/m(2) (28·6 per cent). Earlier band removal was seen in younger patients (P = 0·002). Rates of removal decreased yearly. Of bands placed 4 or more years previously, 35·0 per cent required removal. Eighty-three patients (58·0 per cent) who had a LAGB removed went on to have a further bariatric procedure (band to bypass, 66; band to sleeve, 17).

Br J Surg. 2013 Nov;100(12):1614-8. doi: 10.1002/bjs.9284.






Short-term oncological outcomes of robot-assisted gastrectomy are comparable with other approaches


This systematic review compared the outcomes of robot-assisted gastrectomy (RAG) with conventional laparoscopically assisted gastrectomy (LAG) and open gastrectomy (OG) for gastric cancer. Nine non-randomized observational clinical studies involving 7200 patients satisfied the eligibility criteria. RAG was associated with longer operating times than LAG and OG. The number of retrieved lymph nodes and the resection margin length in RAG were comparable with those of LAG and OG. Estimated blood loss was significantly less in RAG than in OG, but not LAG. Mean hospital stay for RAG was similar to that for LAG. In contrast, hospital stay was significantly shorter, by a mean of 2 days, for RAG compared with OG. Complications were similar for all three operative approaches.

Br J Surg. 2013 Nov;100(12):1566-78. doi: 10.1002/bjs.9242.













Lap Hellers demonstrates superior short- and long-term efficacy in treatment of achalasia


The aim of this meta-analysis was to compare short- and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment. Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments [OR = 4.83 (1.87-12.50), 19.61 (5.34-71.95), and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%).

Ann Surg. 2013 Dec;258(6):943-52. doi: 10.1097/SLA.0000000000000212.






Women following bariatric surgery are at increased risk of preterm and small for gestational age births


This population based matched cohort study compared perinatal outcomes in births of women with versus without a history of bariatric surgery in Sweden. Post-surgery births were more often preterm than in matched controls (9.7% (243/2511) v 6.1% (750/12379). Body mass index seemed to be an effect modifier (P=0.01), and the increased risk of preterm birth was only observed in women with a body mass index <35. A history of bariatric surgery was associated with increased risks of both spontaneous and medically indicated preterm birth. A history of bariatric surgery was also associated with an increased risk of a small for gestational age birth and lower risk of a large for gestational age birth. No differences were detected for stillbirth or neonatal death. The increased risks for preterm and small for gestational age birth, as well as the decreased risk for large for gestational age birth, remained when post-surgery births were compared with births of women eligible for bariatric surgery.

BMJ. 2013 Nov 12;347:f6460. doi: 10.1136/bmj.f6460.






Liver cirrhotic patients had increased mortality and complications after non-hepatic surgery


This population based study evaluated the association between liver cirrhosis and adverse outcomes after non-hepatic surgery in Taiwan. Thirty-day mortality rates among 24282 patients with cirrhosis and 97128 control patients were 1·2 per cent (299 deaths) and 0·7 per cent (635 deaths) respectively. Liver cirrhosis was associated with postoperative 30-day mortality (OR 1·88, 95 per cent c.i. 1·63 to 2·16), acute renal failure (OR 1·52, 1·34 to 1·74), septicaemia (OR 1·42, 1·33 to 1·51) and intensive care unit admission (OR 1·39, 1·33 to 1·45). Postoperative mortality increased in patients who had liver cirrhosis with viral hepatitis (OR 2·87, 1·55 to 5·30), alcohol dependence syndrome (OR 3·74, 2·64 to 5·31), jaundice (OR 5·47, 3·77 to 7·93), ascites (OR 5·85, 4·62 to 7·41), gastrointestinal haemorrhage (OR 3·01, 2·33 to 3·90) and hepatic coma (OR 5·11, 3·79 to 6·87).

Br J Surg. 2013 Dec;100(13):1784-90. doi: 10.1002/bjs.9312.










No association between operating the night before and complications following next day cholecystectomy


This study assessed if surgeons operating the night before have more complications of elective surgery performed the next day in a population-based, matched, retrospective cohort study using administrative health care databases in Ontario, Canada. Participants were 2078 patients who underwent elective laparoscopic cholecystectomies performed by surgeons who operated the night before, matched with 4 other elective laparoscopic cholecystectomy recipients. In total, 94,183 eligible elective laparoscopic cholecystectomies were performed. No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night. There was no association between operating the night before vs not operating the night before, and risk of iatrogenic injuries or death.

JAMA. 2013 Nov 6;310(17):1837-41. doi: 10.1001/jama.2013.280372.






Chronic opioid use was greater following bariatric surgery for obesity


The aim of this study was to determine opioid use following bariatric surgery in patients using opioids chronically for pain control prior to their surgery and to determine the effect of preoperative depression, chronic pain, or postoperative changes in body mass index (BMI) on changes in postoperative chronic opioid use. Before surgery, 8% (95% CI, 7%-8%; n = 933) of bariatric patients were chronic opioid users. Of these individuals, 77% (95% CI, 75%-80%; n = 723) continued chronic opioid use in the year following surgery. Mean daily morphine equivalents for the 933 bariatric patients who were chronic opioid users before surgery were 45.0 mg (95% CI, 40.0-50.1) preoperatively and 51.9 mg (95% CI, 46.0-57.8) postoperatively (P < .001). For this group with chronic opiate use prior to surgery, change in morphine equivalents before vs after surgery did not differ between individuals with loss of more than 50% excess BMI vs those with 50% or less vs ≤50% BMI loss. In other subgroup analyses of preoperative chronic opioid users, changes in morphine equivalents before vs after surgery did not differ between those with or without preoperative diagnosis of depression or chronic pain; chronic pain only; both depression and chronic pain; neither depression nor chronic pain; and P values for model interactions when compared with neither were P = .42 for depression, P = .76 for pain, and P = .48 for both.

JAMA. 2013 Oct 2;310(13):1369-76. doi: 10.1001/jama.2013.278344.





Delayed gastric emptying affects long-term results of lap fundoplication for GERD


This study evaluated the long-term effect of laparoscopic total fundoplication (LTF) on symptoms and reflux control in patients with combined (acidic and weakly acidic) (CR) or weakly acidic reflux (WAR), according to the gastric emptying (GE) rate in 188 patients. Quality of life at 12 and 60 months improved in patients with normal GE but not in delayed gastric emptying (DGE) patients. Manometric values of "gastroesophageal junction" significantly increased at 12 and 60 months in all patients with normal GE, whereas the values returned to the baseline at 60 months in 66.7% of DGE patients. Acidic and liquid reflux episodes significantly reduced in both groups, whereas a significant reduction of WAR and mixed (gas + liquid) reflux episodes occurred only in patients with normal GE (P < 0.001).

Ann Surg. 2013 Nov;258(5):831-7. doi: 10.1097/SLA.0b013e3182a6882a.









Identification of PET-positive lymph nodes after completion of chemotherapy is a predictor of poor prognosis of patients with oesophageal cancer

This study in the BJS investigated the relevance of FDG-PET-positive lymph nodes after neoadjuvant chemotherapy for squamous cell oesophageal cancer. Before therapy, 156 (73·9 per cent) of 211 patients had PET-positive nodes, of whom 89 (57.1 per cent) had no evidence of metabolic activity in these lymph nodes following chemotherapy. There was a significant relationship between post-treatment lymph node status assessed by FDG-PET and numbers of pathologically confirmed metastatic lymph nodes. Patients with post-treatment PET-positive nodes had shorter survival than those without (5-year survival rate 25 versus 62·6 per cent; P < 0·001). Multivariable analysis identified post-treatment nodal status assessed by FDG-PET and tumour depth as independent prognostic factors.
Br J Surg. 2013 Oct;100(11):1490-7. doi: 10.1002/bjs



Bariatric surgery can induce remission and improvement of T2DM in severely obese patients
This study in the Annals of Surgery evaluated the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors in 217 patients. At a median follow-up of 6 years, after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P < 0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (>1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P < 0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015).
Ann Surg. 2013 Oct;258(4):628-37. doi: 10.1097/SLA.0b013e3182a5034b.

Annual national hospital expenditures are $160 million higher in obese than in a comparative group of nonobese patients

This study evaluates the economic impact of obesity on hospital costs associated with the commonest nonbariatric, nonobstetrical surgical procedures. Of 2,309,699 procedures, 439,8129 (19%) were successfully matched into 2 medically equal groups (obese vs nonobese). Adjusted total hospital costs incurred by obese patients were 3.7% higher with a significantly (P < 0.0001) higher per capita cost of $648 (95% confidence interval [CI]: $556-$736) compared with nonobese patients. Of the 2 major components of hospital costs, length of stay was significantly increased in obese patients (mean difference = 0.0253 days, 95% CI: 0.0225-0.0282) and resource utilization determined by costs per day were greater in obese patients due to an increased number of diagnostic and therapeutic procedures needed postoperatively (odds ratio [OR] = 0.94, 95% CI: 0.93-0.96). Postoperative complications were equivalent in both groups (OR = 0.97, 95% CI: 0.93-1.02).
Ann Surg. 2013 Oct;258(4):541-53. doi: 10.1097/SLA.0b013e3182a500ce.



Underweight or overweight patients undergoing gastrointestinal cancer surgery have more postop complications

This study in the BJS investigated the relationship between body mass index (BMI) and outcomes after gastrointestinal surgery in 30 765 patients. A BMI of 18·5 kg/m(2) was associated with significantly greater mortality (odds ratio (OR) 2·04, 95 per cent confidence interval 1·64 to 2·55), postoperative complications (OR 1·10, 1·03 to 1·18) and total costs (difference €1389, 1139 to 1640) compared with a BMI of 23·0 kg/m(2) . Patients with a BMI exceeding 30·0 kg/m(2) had significantly higher rates of postoperative complications and total costs than those with a BMI of 23·0 kg/m(2) , but no significant association was evident between a BMI of more than 23·0 kg/m(2) and in-hospital death.
Br J Surg. 2013 Sep;100(10):1335-43. doi: 10.1002/bjs.9221.





Underweight or overweight patients had more postoperative complications following cancer surgery

The results from the relatively obese population in Western countries may not be generalizable to Asian countries, prompting the present study to investigate the relationship between body mass index (BMI) and outcomes after gastrointestinal surgery. Patients who underwent gastrectomy or colorectal resection for stage I-III cancer between July and December 2010 were identified from a nationwide inpatient database in Japan. Among 30 765 eligible patients, associations between BMI and the outcomes were U-shaped, with the lowest mortality, morbidity and total costs in patients with a BMI of around 23·0 kg/m(2) . A BMI of 18·5 kg/m(2) was associated with significantly greater mortality (odds ratio (OR) 2·04, 95 per cent confidence interval 1·64 to 2·55), postoperative complications (OR 1·10, 1·03 to 1·18) and total costs (difference €1389, 1139 to 1640) compared with a BMI of 23·0 kg/m(2) . Patients with a BMI exceeding 30·0 kg/m(2) had significantly higher rates of postoperative complications and total costs than those with a BMI of 23·0 kg/m(2) , but no significant association was evident between a BMI of more than 23·0 kg/m(2) and in-hospital death.

Br J Surg, 2013;100(10):1335-43.





Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett esophagus

This review investigates current concepts on the pathogenesis, diagnosis, and treatment of Barrett esophagus; discusses the importance of dysplasia and the role of endoscopic eradication therapy for its treatment; and reviews current management guidelines. Risk factors for cancer in Barrett esophagus include chronic GERD, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity with an intra-abdominal body fat distribution. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. High-quality studies have found no significant differences in cancer incidence for patients with Barrett esophagus whose GERD is treated medically or surgically. Endoscopic eradication therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for patients with high-grade dysplasia.

JAMA, 2013;310(6):627-36.






Laparoscopic fundoplication is a cost-effective alternative to continued medical management for GORD

This study evaluated the long-term health benefits, costs and cost-effectiveness of laparoscopic fundoplication compared with continued medical management in patients with GORD. The group randomized to surgery experienced better health outcomes in each year of follow-up, but the difference narrowed over time. At 5 years, the surgery group had experienced 0·216 (95 per cent confidence interval 0·021 to 0·412) more QALYs but also accrued €1832 (1214 to 2448) more costs. The incremental cost-effectiveness ratio was €8481 per QALY gained. The probability that surgery is the most cost-effective intervention was 0·932 at a threshold of €24 134/QALY (£20 000/QALY). Results were robust to most sensitivity analyses, except where patients with missing data randomized to surgery were assumed to have worse health outcomes.

Br J Surg, 2013;100(9):1205-13.





Error rating tool allows an objective assessment of operative performance in lap gastric bypass

The aim of the present study was to design and validate a technical error rating tool in laparoscopic surgery using unedited videos of laparoscopic Roux-en-Y gastric bypass procedures. Two observers analysed 25 procedures. Inter-rater reliability was high regarding total number of errors and events. The median (interquartile range) error rate was 35 (26-44) and the event rate 3 (2-3) per procedure. Error frequencies and OSATS scores correlated significantly in all operative steps. Surgeons demonstrating high OSATS scores had lower median (i.q.r.) error rates than surgeons with low scores in three of four steps: measuring bowel (4 (2-7) versus 10 (9-11); P = 0·004), jejunojejunostomy formation (5 (2-6) versus 10 (9-11); P = 0·001) and pouch formation (4 (3-6) versus 9 (5-12); P = 0·004).

Br J Surg, 2013;100(8):1080-8.





Proximal margin lengths of >20 mm is satisfactory in type II/III oesophagogastric cancer treated by transhiatal gastrectomy

This study investigated whether a shorter proximal margin might suffice in the context of total gastrectomy for Siewert type II and III tumours in 120 patients. Two patients (1·4 per cent) had histologically positive proximal margins and another two (1·4 per cent) developed anastomotic recurrence. Of 100 patients with pT2-4N0-3M0 tumours who underwent gastrectomy via a transhiatal approach, those with gross proximal margins larger than 20 mm appeared to have better survival than those with shorter margins (P = 0·027). Multivariable analysis demonstrated that a gross proximal margin of 20 mm or less was an independent prognostic factor (hazard ratio (HR) 3·56, 95 per cent confidence interval 1·39 to 9·14; P = 0·008), as was pathological node status (HR 1·76, 1·08 to 2·86; P = 0·024).

Br J Surg, 2013;100(8):1050-4.





CRM of 1 mm or less should be regarded as involved in for oesophageal cancer surgery

The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM. A total of 226 patients were included. Sex, tumour differentiation, lymph node status, number of positive nodes, and CRM distance were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1-0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables .

Br J Surg, 2013;100(8):1055-63.




Among patients with Barretts approximately 2% will die of esophageal cancer within 10 years

The authors investigated the causes of death in people with Barrett's esophagus (BE) by linking the UK's Clinical Practice Research Datalink and with information from England's Hospital Episode Statistics database. Eligible patients (N = 8448) were matched with individuals without BE for age, sex, and general practice (controls, N = 155,212). Compared with the control population, patients with BE had increased risks of death from neoplasms and from respiratory and digestive causes but not from circulatory disorders. The annual mortality rate from esophageal cancer among patients with BE was 0.14%; 4.5% of deaths among these patients resulted from this cancer, leading to a cumulative 10-year risk of almost 2%. Nonetheless, the largest single cause of death among patients with BE was ischemic heart disease (5.6 per 1000 patients); 168 patients with BE died of this cause, nearly 4-fold the number that died of esophageal cancer.

Gastroenterology, 2013;144(7):1375-1383.e1.






Minimally invasive esophagectomy is cost-effective compared to open in esophageal cancer

The objective of this study was to determine the cost-effectiveness of minimally invasive (MIE) compared to open esophagectomy for esophageal cancer. MIE was estimated to cost $1641 less than open esophagectomy, with an incremental gain of 0.022 QALYs. MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Ann Surg Oncol, 2013; DOI:10.1245/s10434-013-3103-6




En bloc multivisceral resection in locally advanced gastric cancer can be performed if complete resection can be realistically obtained

The authors analyzed the role of multivisceral resection for locally advanced gastric cancer with particular attention to the brief and long-term results and to the prognostic value of clinical and pathologic factors over an 18 year period. A total of 2208 patients underwent curative resections for gastric carcinoma and 206 patients presented with a clinical T4b carcinoma. One hundred twelve underwent a combined resection of the adjacent organs with a gastrectomy owing to suspicion or direct invasion of these organs by the gastric cancer. Postoperative mortality and complication rates of patients who underwent a gastrectomy with a combined resection of the involved organs were 3.6% and 33.9%, respectively. Pathologic factors revealed that the nodal involvement was present in about 89.3% of patients and the mean (SD) number of pathologic lymph nodes was 14.8 (16.6). The overall 5-year survival rate was 27.2%. The completeness of resection and lymph node invasion represent independent prognostic parameters at multivariate analysis.

JAMA Surg, 2013;148(4):353-60.





Idiopathic chronic cough maybe due to laryngopharyngeal reflux and respond to antireflux surgery

The aim was to define the patterns of reflux and assess the outcome of antireflux surgery (ARS) in patients with chronic cough who were selected using hypopharyngeal multichannel intraluminal impedance (HMII). A total of 314 symptomatic patients underwent HMII. Of this population, 49 patients (15 men, 34 women; median age, 57 years) were identified as having chronic coughcaused by gastroesophageal reflux disease. Of the 49 participants, 23 of 44 patients (52%) had objective findings of gastroesophageal reflux disease, such as esophagitis. Abnormal proximal exposure was discovered in 36 of the 49 patients (73%). Of 16 patients with abnormal proximal exposure who subsequently underwent ARS, 13 patients (81%) had resolution of cough and 3 patients (19%) had significant improvement at a median follow-up of 4.6 months (range, 0.5-13 months).

JAMA Surg, 2013;22:1-8.




Certain antidepressive medication is associated with perioperative adverse events

The aim is to determine whether perioperative use of selective serotonin reuptake inhibitors (SSRIs) is associated with adverse outcomes of surgery in a national sample of patients (n=530416). Patients receiving SSRIs were more likely to have obesity, chronic pulmonary disease, or hypothyroidism and more likely to have depression. After adjustment, patients receiving SSRIs had higher odds of in-hospital mortality, bleeding and readmission at 30 days. Similar results were observed in propensity-matched analyses, although the risk of inpatient mortality was attenuated among patients with depression.

JAMA Intern Med, 2013;29:1-7.





Erosion of Lap Band is uncommon but has a benign clinical course

This study defines the changing prevalence of erosion after Laparoscopic Adjustable Gastric Banding (LAGB), describing the range of clinical presentations, the approaches to treatment and the outcomes from these approaches over a 15-year study period. 2986 patients were identified. Hundred erosions were experienced by 85 patients (2.85%) at a median time of 33 months from initial surgery to the erosion. The rate of erosion was highest when the band was placed by the perigastric approach at 6.77%. Since the adoption of the pars flaccida approach, the rate of erosion has dropped to 1.07%. The most common presentation was loss of satiety. The band has been successfully replaced in 56 patients. It has been explanted in 27 patients and 2 patients were converted to other bariatric procedures. The weight loss in patients who had a LAGB reinserted after erosion was not significantly different to the background cohort.

Ann Surg, 2013 Jun;257(6):1047-52.




Proximal gastrectomy is associated with worse quality of life than other gastric resections

This study assessed differences in quality of life (QOL) among patients after distal (DG, n=82), proximal (PG, n=16), or total (TG, n=36) gastrectomy. In the immediate postoperative period, 55% of patients suffered significant impairment in their global QOL. This improved in most patients by 6 months, although 20% to 35% continued to have substantially worse QOL than before surgery. Patients who underwent PG suffered from significantly more clinical reflux [70% vs 35% (DG), 40% (TG)], nausea/vomiting (60% vs 25%, 30%), and global QOL impairment (60% vs 30%, 30%) than patients who underwent DG or TG, whose QOL scores were similar. These differences persisted up to 18 months postoperatively.

Ann Surg, 2013;257(6):1039-46.





Obesity doesnt affect the quality of oncological oesophageal resection in high volume centre

The aim of this retrospective study was to determine the relationship between preoperative body mass index (BMI) on perioperative complications after oesophagectomy for adenocarcinoma of the oesophagus. Patients were stratified according to BMI: 155 normal-weight (BMI 20-24), 198 overweight (BMI 25-29) and 187 obese (BMI ≥30) patients. The patient cohort consisted of 474 men and 66 women with a mean age of 64.3 years (28-86). They were similar in terms of demographics and comorbidities, with the exception of a younger age (65.2 vs 65.4 vs 62.5 years, p=0.0094), and a higher incidence of diabetes (9.1% vs 13.2% vs 22.7%, p=0.001), hiatal hernia (16.8% vs 17.8% vs 28.8%, p=0.009) and Barrett oesophagus (24.7% vs 25.4% vs 36.2%, p=0.025) for obese patients. The type of surgery performed, overall blood loss, extent of lymphadenectomy, R0 resections and complications were not influenced by BMI on univariate and multivariate analysis.

BMJ Open, 2013;3(5):e001336.




Postop complications are currently more frequently in lap total gastrectomy

This study was designed to compare short-term laparoscopic total gastrectomy (LTG) with open total gastrectomy (OTG) outcomes in 70 patients matched for stage, age, and sex. Although the operation time was not longer for LTG, the incidence of anastomotic complications such as leak and stenosis was higher in the LTG group as well.

Am J Surg, 2013;doi:10.1016/j.amjsurg.2012.11.011.





GERD recurs in 43% of children after 10 to 15 years after lap fundoplication

The aim was to study the long-term (10-15 years) efficacy of antireflux surgery (ARS) in a prospectively followed cohort of 57 pediatric patients with gastroesophageal reflux disease, using 24-hour pH monitoring and reflux-specific questionnaires. At 3 to 4 months, at 1 to 5 years, and at 10 to 15 years after ARS, 81%, 80%, and 73% of patients, respectively, were completely free of reflux symptoms. Total acid exposure time significantly decreased from 13.4% before ARS to 0.7% (P < 0.001) at 3 to 4 months after ARS; however, at 3 to 4 months after ARS, pH monitoring was still pathological in 18% of patients. At 10 to 15 years after ARS, the number of patients with pathological reflux had even significantly increased to 43% (P = 0.008).

Ann Surg, 2013; In Press




Single-incision lap cholecystectomy is associated with increase in hernia formation

This study presents the 1-year results of a prospective, randomized, multicenter, single-blinded trial of single-incision laparoscopic cholecystectomy (SILC) vs multiport cholecystectomy (4PLC). Two hundred patients underwent randomization to SILC (n = 119) or 4PLC (n = 81). Total adverse or severe adverse events were not significantly different between groups. Incision-related adverse events were higher after SILC. Total hernia rates were 1.2% in 4PLC patients vs 8.4% in SILC patients. At 1-year follow-up, cosmesis scores continued to favor SILS.

J Am Coll Surg, 2013;doi: 10.1016/j.jamcollsurg.2013.02.024




Socio-demographic inequalities appear in esophageal and gastric cancer mortality

This population-based cohort study included all Swedish residents aged 30-84 years in 1990-2007 to investigate the socio-demographic factors and area of residence and the development of esophageal and gastric cancer. Among 84 920 565 person-years, 5125 and 12 230 deaths occurred from esophageal cancer and gastric cancer, respectively. Higher educational level decreased the hazard ratio (HR) of esophageal cancer and gastric cancer. Being unmarried increased HR of esophageal cancer, but not of gastric cancer. Being born in low density populated areas increased HR of gastric cancer only. Living in densely populated areas increased HR of esophageal cancer, but not of gastric cancer.

PLoS One, 2013;8(4):e62067





Nodal ratio seems to be a simple method to predict the prognosis of patients with gastric cancer

The aim of this study is to evaluate the prognostic role of nodal ratio (NR) comparing it with the new TNM (2010) classification. 142 patients were submitted to potentially curative gastrectomy for cancer. Patients with low performance status underwent D1.5 lymphadenectomy, whereas the other patients underwent D2-D2.5 lymphadenectomy. Nodal staging was classified according to 2010 International Union Against Cancer/American Joint Committee on Cancer classification. Kaplan-Meier method was used to evaluate survival, stratified for nodal classes and nodal status. Total gastrectomy was performed in 39 per cent of cases and distal gastrectomy in 61 per cent. Mean number of resected nodes was 25.5. Whereas N status was strictly related to the number of resected nodes, the NR was independent from the extension of the lymphadenectomy. Overall five-year survival was 81 per cent for N0 patients, 72 per cent for N1, and 26 and 23 per cent for N2 and N3, respectively. Patients with NR0 had 81 per cent five-year survival, whereas NR1 67 per cent, NR2 51 per cent, and NR3 22 per cent.

Am Surg, 2013;79(5):483-91.




Addition of cetuximab to chemotherapy & radiotherapy is not recommended in oesophageal cancer

This multicentre, randomised, open-label, phase 2/3 trial aimed to investigate the addition of cetuximab to cisplatin and fluoropyrimidine-based definitive CRT in patients with localised oesophageal squamous-cell cancer and adenocarcinomas to assess activity, safety, and feasibility of use. Patients were randomly assigned to receive CRT alone or CRT with cetuximab, stratified by recruiting hospital, primary reason for not having surgery, tumour histology, and tumour stage. 258 patients (129 assigned to each treatment group) from 36 UK centres were recruited. Recruitment was stopped without continuation to phase 3 because the trial met criteria for futility. Fewer patients were treatment failure free at 24 weeks in the CRT plus cetuximab group than in the CRT only group. The CRT plus cetuximab group also had shorter median overall survival (22·1 months vs 25·4 months). Patients who received CRT plus cetuximab had more non-haematological grade 3 or 4 toxicities and dysphagia.

Lancet Oncol. 2013;doi: 10.1016/S1470-2045(13)70136-0





Lap fundoplication provides better relief of GORD symptoms than medical management

The authors attempted to determine the long term clinical effectiveness of laparoscopic fundoplication as an alternative to drug treatment for chronic gastro-oesophageal reflux disease (GORD) in a multicentre, pragmatic randomised trial. By five years, 63% of patients randomised to surgery and 13% of those randomised to medical management had received a fundoplication plus 85% and 3% of those who expressed a preference for surgery and for medical management respectively. Among responders at 5 years, 44% of those randomised to surgery were taking antireflux medication versus 82% of those randomised to medical management. Differences in the REFLUX score significantly favoured the randomised surgery group. SF-36 and EQ-5D scores also favoured surgery, but were not statistically significant at five years. After fundoplication, 3% had surgical treatment for a complication and 4% had subsequent reflux-related operations-most often revision of the wrap. Long term rates of dysphagia, flatulence, and inability to vomit were similar in the two randomised groups.

BMJ, 2013;346:f1908.




Metallic clips demonstrate the highest burst pressures when used to seal the cystic duct

The objective of this study was to test the strength of 3 different cystic duct closure methods (metal clips vs. Endoloops vs. ENSEAL tissue sealing device) in a model simulating postoperative biliary insufflation. The extrahepatic biliary system, including common bile duct, gallbladder, and cystic duct, was harvested en bloc from 22 swine postmortem. A cholecystectomy was performed and the cystic duct was secured. The common bile duct was cannulated with a pressure-monitoring system and insufflated with air. The burst pressures, location of rupture, and size of the common bile duct and cystic duct were recorded and compared. There were 7 pigs each in the ENDOLOOP and ENSEAL groups and 8 in the metallic clip group, with no statistical significance between cystic and common bile duct size. Mean burst pressure was 432 mm Hg for metallic clips, 371 mm Hg for the ENDOLOOP, and 238 mm Hg for the ENSEAL device (P = .02). Post hoc analysis revealed clips to be statistically superior when compared with the ENSEAL (P= .01). There was no statistical difference between the ENDOLOOP and metal clips or between the ENDOLOOP and the ENSEAL.

Am J Surg, 2013;205(5):547-51.




Gastroesophageal resections units with low mortality rates are more likely to reintervene

This study compares the outcomes following operative and non-operative reinterventions between high- and low-mortality following esophagectomies (n=14 955) and gastrectomies (n=10 671) performed in 141 units in the UK. For gastroesophageal resections combined, adjusted mortality rates were 3.0% and 8.3% for low- and high-mortality units (LMUs and HMUs) respectively. Complications rates preceding reoperation were similar (5.4% for LMUs vs 4.9% for HMUs). The failure to rescue-surgical rates were lower in LMUs than in HMUs (15.3% vs 24.1%). The LMUs performed more non-operative reinterventions than the HMUs did (6.7% vs 4.7%), with more patients surviving in LMUs than in HMUs (failure to rescue rate, 7.0% vs 12.5%). Overall, LMUs reintervened more than HMUs did (12.2% vs 9.6%), and LMUs had lower failure to rescue rates following reintervention than HMUs did (9.0% vs 18.3%).

JAMA Surg, 2013:1;148(3):272-6.





Advanced junctional and gastric adenocarcinoma disease heightens the risk of postop mortality

The authors aimed to identify factors predictive of mortality within 30 days of junctional (n=774) and gastric adenocarcinoma (n=1896) resection in a retrospective multicenter cohort. Neoadjuvant treatment was given to 655 patients and 114 patients died within 30 days of surgery. Postoperative mortality was higher in patients who experienced grades III and IV toxic effects during neoadjuvant treatment compared with those who did not (8.7% vs 2.9%, respectively). Multivariate analysis revealed metastatic disease at diagnosis and poor tolerance of neoadjuvant treatment as being independently predictive of postop mortality (POM). Centers performing at least 10 resections per year were found to be protective against POM.

JAMA Surg, 2013;20:1-8.




Real time cancer diagnosis based on in vivo tissue compliance measurements is feasible

This feasibility study investigates real time cancer tissue diagnosis intraoperatively based on in vivo tissue compliance measurements obtained by a recently developed laparoscopic smart device (A Clinical Real Time Tissue Compliance Mapping System (CRTCMS)). The system demonstrated a high prediction power to diagnose cancer tissue in real time during routine surgical procedures (sensitivity = 98.7%, specificity = 99%) includes 10 esophageal and 27 gastric cancer patients. An in vivo human tissue compliance data bank of the gastrointestinal tract was produced.

Ann Surg, 2013; doi: 10.1097/SLA.0b013e31828ccf43







Drug eluting stents appear more effective for benign cardia stricture than bare stents

This study evaluated a biodegradable paclitaxel-eluting nanofibre-covered metal stent for the treatment of benign cardia stricture in vitro and in vivo. Eighty dogs were divided randomly into four groups (each n=20): controls (no stent), bare stent (retained for 1 week), and two drug-eluting stent (DES) groups with retention for either 1 week (DES-1w) or 4 weeks (DES-4w). Stent migration rates were similar. The percentage and amount of paclitaxel released in vitro was higher at pH 4·0 than at pH 7·4. After 6 months, lower oesophageal sphincter pressure and 5-min barium height were both improved in the DES-1w and DES-4w groups compared with the bare-stent group, with better relief when the stent was retained for 4 weeks. The DES was associated with a reduced peak inflammatory reaction and less scar formation compared with bare stents, especially when inserted for 4 weeks.

Br J Surg, 2013;100(6):784-93




Patients may be at increased risk for substance use following bariatric surgery

The authors assessed substance use before and after bariatric weight loss surgery (WLS) in 155 participants (132 women and 23 men). Participants reported significant increases in the frequency of substance use (a composite of drug use, alcohol use, and cigarette smoking, hereafter referred to as composite substance use) 24 months after surgery. Specifically, participants experienced a significant increase in the frequency of composite substance use from baseline to 24 months after surgery. In addition, participants who underwent laparoscopic Roux-en-Y gastric bypass surgery reported a significant increase in the frequency of alcohol use from baseline to 24 months after surgery.

JAMA Surg, 2013;148(2):145-50.








KRAS mutations and DNA MMR deficiency have a role in a small subgroup of gastric cancer

The prevalence of KRAS and BRAF mutations was established in 712 gastric cancer (GC): 278 GC from the United Kingdom, 230 GC from Japan and 204 GC from Singapore. The relationship between KRAS/BRAF mutation status, DNA mismatch repair (MMR) status, clinicopathological variables and overall survival was analysed. Overall, 4.2% GC carried a KRAS mutation. In total, 5.8% of the UK GC, 4% of Japan GC and 1.5% of Singapore GC were KRAS mutant. KRAS mutant GC had fewer lymph node metastases in the UK cohort and were more frequent in elderly patients in the Japan cohort. KRAS mutations were more frequent in MMR-deficient GC in the UK and the Japanese cohort.

Br J Cancer, 2013;doi: 10.1038/bjc.2013.109



D2 lymphadenectomy with spleen/pancreas preservation offers the most survival benefit in gastric cancer

The objective of this meta-analysis was to estimate the magnitude of survival and recurrence free benefits from different lymphadenectomy in patients with resectable gastric cancer. Twelve randomized control trials (RCTs) were eligible for final meta-analysis. There was no significant difference in OS between D1 and D2 lymphadenectomy, but subgroup analysis of patients without splenectomy and/or pancreatectomy has a trend for OS much more benefiting D2 compared to D1 patients. A significant RFS improvement was found in favor of D2 lymphadenectomy, sensitivity analysis also gives similar fixed effect estimates. There were no significant differences in OS and RFS between D2 group and D3 group.

J Surg Oncol, 2013;doi: 10.1002/jso.23325



Minimal LN dissection maybe possible in selected small-sized gastric tumors after endoscopic resection

The purpose of this study was to identify risk factors associated with lymph node (LN) metastasis in early gastric cancer patients who underwent endoscopic resection (ER) and to evaluate the feasibility of minimal LN dissection in 147 patients. The LN metastasis was identified in 12 patients (8.2 %). The incidence of LN metastasis was not significantly increased in patients with submucosal invasion, lymphovascular invasion, and mixed undifferentiated histology. Tumor size >2 cm was significantly associated with LN metastasis. The incidence of LN metastasis gradually increased from 3.2 to 20 %, as number of risk factors increased. LN metastasis was present primarily along the perigastric area in all except two patients (1.4 %) with skip metastasis to extragastric area.

Surg Endosc, 2013; In Press





BMI, age, male gender and congestive heart failure are risk factors for 30-day mortality after RYGB

These authors sought to identify the major risk factors associated with mortality in Roux-en-Y gastric bypass (RYGB) surgery using clinical outcome data from 157,559 bariatric surgery patients from the Bariatric Outcome Longitudinal Database. The overall 30-day mortality rate for the entire bariatric surgery cohort was 0.1%. Of the 81,751 RYGB patients, the mortality rate was 0.15%. Factors significantly associated with 30-day gastric bypass mortality included increasing body mass index (BMI), increasing age, male gender, pulmonary hypertension, congestive heart failure, and liver disease.

Ann Surg, 2013; doi: 10.1097/SLA.0b013e31828a0ee4



Obesity surgery seems to be associated with an increased risk of colorectal cancer over time

The purpose was to determine whether obesity surgery is associated with a long-term increased risk of colorectal cancer using a nationwide retrospective register-based cohort study in Sweden. Obese individuals were stratified into an obesity surgery (n=15,095) cohort and an obese no surgery cohort (n=62,016). In the obesity surgery cohort, they observed 70 patients with colorectal cancer, rendering an overall standardized incidence ratio (SIR) of 1.60 (95% CI 1.25-2.02). The SIR for colorectal cancer increased with length of time after surgery. In contrast, the overall SIR in the obese no surgery cohort was 1.26 (95% CI 1.14-1.40) and remained stable with increasing follow-up time.

Ann Surg, 2013; doi: 10.1097/SLA.0b013e318288463a







Nodal status has more prognostic impact than R status in stage T3 adenocarcinomas of the esophagus

This study assessed the prognostic values of R0 resection and nodal status in advanced esophageal adenocarcinomas.

Seventy consecutive patients with stage T3 adenocarcinomas of the esophagus or gastric cardia were retrospectively assessed. Neoadjuvant therapy was indicated in all cases. Neoadjuvant therapy was achieved in 62 patients, 41 with radiochemotherapy and 21 with perioperative chemotherapy. Transthoracic esophagectomy and transhiatal esophagectomy were performed in 54 and 15 patients, respectively. In-hospital mortality was 3%. In multivariate analyses, nodal status was the main independent factor predicting overall survival and tumor clearance (R0 or R1) was not statistically significant. Furthermore, R1 resection was a prognostic indicator for metastatic recurrence.

Am J Surg, 2013;doi: 10.1016/j.amjsurg.2012.08.009.



Indocyanine green angiography may be useful to evaluate the gastric conduit perfusion before anastomosis

These authors used indocyanine green tissue angiography to evaluate the gastric conduit intraoperatively before gastroesophageal anastomosis to identify ischemia in 11 patients. All had adequate perfusion on gross examination. All but 1 had good perfusion with tissue angiography, and there were 2 anastomotic leakages leaks including this patient. There were no mortalities at 30 days.

Am J Surg, 2013;doi:10.1016/j.amjsurg.2012.11.005.




NY-ESO-1 may be a useful tumour marker for detecting advanced gastric cancer

The authors analysed whether the NY-ESO-1 humoral immune response is a useful tumour marker of gastric cancer. Serum from 363 gastric cancer patients were screened by ELISA to detect NY-ESO-1 antibodies. NY-ESO-1 antibodies were detected in 3.4% of stage I, 4.4% of stage II, 25.3% of stage III, and 20.0% of stage IV patients. The frequency of antibody positivity increased with disease progression. When the NY-ESO-1 antibody was used in combination with carcinoembryonic antigen and CA19-9 to detect gastric cancer, information gains of 11.2% in stages III and IV, and 5.8% in all patients were observed. The NY-ESO-1 immune response levels of the patients without recurrence fell below the cutoff level after surgery.

Br J Cancer, 2013;doi: 10.1038/bjc.2013.51.







Bariatric surgery may not reduce overall health care costs in the long term

The aim of this study was to provide comprehensive, multiyear analysis of health care costs by type of bariatric procedure compared with a matched nonsurgical cohort. Total costs were greater in the bariatric surgery group during the second and third years following surgery but were similar in the later years. However, the bariatric group's prescription and office visit costs were lower, but their inpatient costs were higher. Those undergoing laparoscopic surgery had lower costs in the first few years after surgery, but these differences did not persist.

JAMA Surg, 2013;doi: 10.1001/jamasurg.2013.1504



Inflammatory markers recover to normal levels following bariatric surgery

The aim of this study was to assess the soluble CD40 ligand (sCD40L) and other factors implicated in coagulation (plasminogen activator inhibitor 1, antithrombin III, and fibrinogen) and inflammation (C-reactive protein) in patients with morbid obesity before and after weight loss induced by bariatric surgery (34 morbidly obese patients undergoing gastric bypass surgery and 22 normal-weight controls matched for age and sex). Obese men showed a tendency for decreased plasma sCD40L levels 1 year after surgery, whereas there were not any significant changes in obese women. Levels of the other markers studied decreased significantly with weight loss in both sexes. However, all other studied markers tend to have higher concentrations in patients with higher BMIs, except for sCD40L, which tended to have lower concentrations in patients with BMIs higher than 55.

JAMA Surg, 2013;148(2):151-6








Lap gastrectomy with D2 lymphadenectomy is safe in advanced gastric cancer

This prospective phase II clinical trial addressed the feasibility of Laparoscopic Gastrectomy (LG) in advanced gastric cancer (AGC) in 157 patients. Conversion to open surgery occurred in 11 patients (7.0 %). The mean hospital stay was 6.3 days for distal gastrectomy and 8.5 days for total gastrectomy. The mean number of collected lymph nodes was 53 for distal gastrectomy and 64 for total gastrectomy. The rates of local and systemic complications of grade II or more were 8.3 and 3.2 %. One patient died of operative complications. In multivariate analysis, old age (>70 years) was an independent risk factor for complications, and old age and Billroth I anastomosis were predictable risk factors for local complications.

Surg Endosc, 2013; DOI:10.1007/s00464-013-2848-0



MRI may improve oesophageal cancer staging, tumour delineation and assessment of treatment response

This systemic review outlines the current role and future potential of MRI in the management of oesophageal cancer. Similar or even better results have been achieved using optimised MRI compared with other imaging strategies for T- and N-staging. No studies clearly report on the role of MRI in oesophageal tumour delineation and real-time guidance for radiotherapy so far. Recent pilot studies showed that functional MRI might be capable of predicting pathological response to treatment and patient prognosis.

Eur Radiol, 2013; DOI:10.1007/s00330-013-2773-6



Semi-mechanical esophagogastric anastomosis could prevent stricture formation

The present randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture. 155 consecutive patients with esophageal carcinoma underwent surgical treatment and were randomised to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis.The anastomotic stricture rate was 0 % in the SM group, 9.6 % in the HS group, and 19.1 % in the CS group. The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group. The reflux/regurgitation score among the three groups was similar.

World J Surg, 2013; DOI: 10.1007/s00268-013-1932-x






Bariatric surgery produces a 65% reduction in macro- and microvascular events in obese T2DM patients

This large, population-based, retrospective cohort study compared patients with T2DM undergoing bariatric surgery (BAR [n = 2,580]) with with nonbariatric surgery controls (CON [n = 13,371]) for the outcomes of any first major macrovascular or microvascular event. Bariatric surgery was associated with favorable unadjusted 5-year event-free survival estimates for the combined primary outcome and each secondary outcome. Multivariate-adjusted and propensity-based relative risk estimates showed BAR to be associated with a 60% to 70% reduction in the combined primary outcome and 60% to 80% risk reductions for each secondary outcome.

J Am Coll Surg, 2013;doi: 10.1016/j.jamcollsurg.2012.12.019



Reversal of T2DM after RYGB linked to increases of insulin secretion rate with restoration of the first-phase insulin secretion

This study evaluated the mechanisms of improvement/reversal of type 2 diabetes after Roux-en-Y gastric bypass (RYGB) in 14 morbidly obese subjects (7 with normal glucose tolerance and 7 with type 2 diabetes) and compared to Six healthy volunteers were used as controls. Total OGTT insulin secretion rate largely increased in postop diabetic subjects only when glucose was administered orally. The first-phase insulin secretion was restored in type 2 diabetic after the intravenous glucose tolerance test postoperatively. Quantitative insulin sensitivity check index was improved in all normotolerant and diabetic subjects. GIP and GLP-1 levels increased both at fast and after OGTT mainly in type 2 diabetic subjects.

Ann Surg, 2013;doi: 10.1097/SLA.0b013e318269cf5c.



Use of sleeve gastrectomy has markedly increased in prevalence globally

This global survey was sent to the leadership of the 50 national groupings in the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to examine the numbers of metabolic/bariatric operations and surgeons and types of procedures performed between 2003 to 2008 to 2011. The response rate was 84 %. The global total number of procedures in 2011 was 340,768; the global total number of metabolic/bariatric surgeons was 6,705. The most commonly performed procedures were Roux-en-Y gastric bypass (RYGB) 46.6 %; sleeve gastrectomy (SG) 27.8 %; adjustable gastric banding (AGB) 17.8 %; and biliopancreatic diversion/duodenal switch (BPD/DS) 2.2 %. The global trends from 2003 to 2008 to 2011 showed a decrease in RYGB; an increase, followed by a steep decline, in AGB; and a marked increase in SG and BPD/DS declined. The trends from the four IFSO regions differed, except for the universal increase in SG.

Obes Surg, 2013; DOI:10.1007/s11695-012-0864-0




Surgery and radiation are associated with increased survival in a subset of metastatic gastric cancer

The purpose of this study was to compare outcomes of metastatic gastric cancer patients stratified by surgery and radiation therapyusing the SEER database. Patients were divided into 4 groups: group 1, no surgery or radiation; group 2, radiation alone; group 3, surgery alone; group 4, surgery and radiation. A total of 5072 patients were identified with AJCC M1 stage IV gastric cancer. Surgery and/or radiation were associated with a survival benefit. Median and 2-year survival for groups 1, 2, 3, and 4 was 7 months and 8.2%, 8 months and 8.9%, 10 months and 18.2%, and 16 months and 31.7%, respectively. Multivariate analysis for all patients revealed that surgery and radiation were associated with decreased mortality whereas T-stage, N-stage, age, signet ring histology, and peritoneal metastases were associated with increased mortality. In patients treated with surgery, radiation was associated with decreased mortality, whereas T-stage, N-stage, age, removal of < 15 lymph nodes, signet ring histology, and peritoneal metastases was associated with increased mortality.

Cancer, 2013;doi:10.1002/cncr.27927.




Prevalence of coexisting colorectal neoplasm is higher in gastric cancer patients than in the normal population

This study evaluated the prevalence of coexisting asymptomatic colorectal neoplasm (CRN) in patients with gastric cancer (GC). Preoperative colonoscopic examinations were performed in 495 patients with GC who underwent gastrectomy and were compared to the prevalence of CRN in 495 sex- and age-matched controls from the normal population. The prevalence of overall CRN, high-risk CRN, and colorectal carcinoma (CRC) were significantly higher in the GC group than in the control group. The presence of GC, age ≥50 years, and male sex were risk factors for overall CRN. In patients with GC, age ≥40 years and male sex were risk factors for overall CRN.

Ann Surg Oncol, 2013; 10.1245/s10434-012-2737-0




Association between gastrectomy performed in Eastern countries and improved survival

The purpose of this study was to compare survival rates between the West and East following gastrectomy in randomized, controlled trials (n=25) with appropriate adjustment for confounding variables. There was association between gastrectomy performed in the East and improved 5-year survival and reduced cancer recurrence. Association of improved 5-year survival with surgery in the East remained when meta-regression adjusted for the effect of age, sex, chemotherapy, tumor depth and nodal status, and gastrectomy type. Association of reduced cancer recurrence also persisted with meta-regression adjusting for age, chemotherapy, nodal status, and gastrectomy type.

Ann Surg Oncol, 2013; 10.1245/s10434-012-2862-9







ERAS protocol in the setting of bariatric surgery shortens hospital stay and reduces costs

This study evaluated an enhanced recovery after surgery (ERAS) protocol following sleeve gastrectomy for patients with morbid obesity. 116 patients were included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group by 1 day compared to the control group and 3 days in the historical group. There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS group.

Br J Surg. 2013 Jan 21:482-489




Intraoperative cholangiography can reduce the risk of death after cholecystectomy by 62%

This study determined whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries using data from the Swedish national registry. 51 041 cholecystectomies were registered and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had worse survival than those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62%.

BMJ, 2012;345:e6457







Method of Reconstruction Governs Iron Metabolism After Gastrectomy for Patients with Gastric Cancer.

This study tested the hypothesis that the incidence and timing of the occurrence of iron deficiency after gastrectomy is closely associated with the extent of gastrectomy and the reconstruction method in 381 patients. The prevalence of iron deficiency 3 years after gastrectomy was 69.1%, and iron-deficiency anemia was observed in 31.0% of patients. Iron deficiency developed in 64.8% and 90.5% of patients after distal gastrectomy and total gastrectomy within 3 years after surgery respectively. Iron deficiency was significantly more frequent in women than in men and after gastrojejunostomy than after gastroduodenostomy. Serum ferritin levels were different according to the extent of gastrectomy and reconstruction method. The proportion of patients treated for iron-deficiency anemia was also significantly different according to the extent of gastrectomy.

Annals of Surgery, 2013;doi: 10.1097/SLA.0b013e31827eebc1




CRM involvement is an important predictor of poor prognosis in operable oesophageal cancer

This systematic review and meta-analysis was performed to determine the influence of circumferential resection margin (CRM) involvement on survival in operable oesophageal cancer. Fourteen studies involving 2433 patients with oesophageal cancer who had undergone potentially curative oesophagectomy were analysed. Rates of CRM involvement were 15·3 per cent (173 of 1133) and 36·5 per cent (889 of 2433) according to the College of American Pathologists (CAP) and Royal College of Pathologists (RCP) criteria respectively. Overall 5-year mortality rates were significantly higher in patients with CRM involvement compared with CRM-negative patients according to both CAP and RCP criteria. CRM involvement between 0·1 and 1 mm was associated with a significantly higher 5-year mortality rate than CRM-negative status.

Br J Surg, 2013;doi: 10.1002/bjs.9015.




Log odds of +ve LN scheme staging system is superior in predicting outcome in patients with gastric cancer

This study investigates outcomes in gastric cancer and several node staging schemes (a number-based scheme (pN), ratio-based scheme (rN) and log odds of positive lymph nodes scheme (LODDS)). 12 443 patients were identified from the SEER database and 866 in the Chinese cohort. LODDS provided better discriminatory capacity and higher predictive accuracy than either pN or rN, for patients with gastric cancer in both the SEER database and the Chinese cohort. The multivariable model using the LODDS classification was significantly more predictive than the pN classification. LODDS suffered much less from stage migration and was able efficiently to discriminate the heterogeneity for patients with no nodes involved or all nodes involved.

Br J Surg, 2013;doi: 10.1002/bjs.9014.





A restrictive transfusion strategy improves outcomes in acute upper gastrointestinal bleeding

This study compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. Patients with severe acute upper gastrointestinal bleeding were randomly assigned to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per decilitre, n=461) or to a liberal strategy (transfusion when the hemoglobin fell below 9 g per decilitre, n=460). 51% in the restrictive strategy and 15% in the liberal strategy group did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; p=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01). The probability of survival was significantly higher in the restrictive strategy subgroup of patients with cirrhosis and Child–Pugh class A or B disease but not in those with cirrhosis and Child–Pugh class C disease

N Engl J Med 2013; 368:11-21.




Pre-op model provides a tool to identify bariatric patients at risk of in-hospital mortality

This study aimed to evaluate the factors capable of predicting perioperative mortality based on preoperative characteristics using the ACS-NSQIP database. The study identified 44,408 patients (79 % women, 21 % men) with a mean age of 45 ± 11 years. The cumulative 30-day perioperative mortality rate was 0.14 %. The majority of the procedures performed included laparoscopic gastric bypass (54 %) followed by laparoscopic gastric banding (33 %) and open gastric bypass (7 %). Independent predictors associated with increased mortality included age >45 years, male gender, BMI>50, open bariatric procedures, diabetes, functional status of total dependency before surgery, prior coronary intervention, dyspnea at preoperative evaluation (AOR, 4.64). Risk stratification based on the number of preoperative comorbid factors showed an exponential increase in mortality as follows: 0-1 comorbidities (0.03 %), 2-3 comorbidities (0.16 %), and 4 comorbidities or more (7.4 %).

Surg Endosc, 2013; 10.1007/s00464-012-2678-5.






Racial disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery

The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality. Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer. A total of 6,737 patient files (84 % white, 10 % black, 6 % Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26 %, respectively) and lesions in the mid-esophagus (58 vs. 38 vs. 26 %, respectively). Blacks and Hispanics were less likely to undergo esophagectomy. Black and Hispanic patients had a higher unadjusted risk of mortality. However, differences in mortality were no longer significant after adjusting for receipt of surgery.

Ann Surg Oncol, 2012; DOI:10.1245/s10434-012-2807-3



Lap total gastrectomy shows better short term outcomes in eligible patients with gastric cancer

The possible short-term advantages of laparoscopic (assisted) total gastrectomy (LTG) versus open total gastrectomy (OTG) in the treatment of gastric cancer were systematically reviewed here. A total of eight original studies that compared LTG (n = 314) with OTG (n = 384) in patients with gastric cancer were selected. LTG compared with OTG was associated with a significant reduction of intraoperative blood loss, a reduced risk of postoperative complications, and shorter hospital stay. These benefits were at the cost of longer operative time. In-hospital mortality rates were similar between the groups.

Surg Endosc, 2012; DOI: 10.1007/s00464-012-2661-1





Lap gastric banding demonstrates a durable weight loss with 47% excess weight loss to 15 years

This prospective longitudinal cohort study describes the 15 year outcomes after laparoscopic adjustable gastric banding (LAGB) and compares these with the published literature on bariatric surgery. A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by LAGB and follow-up was complete in 81% of patients overall and 78%. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years. Revisional procedures were performed for proximal enlargement, erosion, port and tubing problems and was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years.

Ann Surg. 2013 Jan;257(1):87-94. doi: 10.1097/SLA.0b013e31827b6c02.




Lap Nissen fundoplication has a very high satisfaction rate overall

This study investigated patients who underwent laparoscopic Nissen fundoplication (n=222) to identify predictors of patient dissatisfaction and the impact of surgery on individual symptoms. The postoperative response rate to the questionnaire was 77.5 % and dissatisfaction was reported by 12.8 %. Of these dissatisfied patients, only 13.6 % had proven disease recurrence. Both satisfied and dissatisfied patients presented with an inconsistent pattern of symptoms. None of the preoperative symptoms and investigations or the patient's age and gender was predictive of postoperative dissatisfaction.

Surg Endosc. 2012;DOI:10.1007/s00464-012-2630-8



There has been an increase in the use of lap sleeve gastrectomy over the past 4 years

The aim of this study was to examine contemporary changes in use and outcomes of bariatric surgery. Between 2008 and 2012 60,738 bariatric procedures were examined. In 2008, the makeup of bariatric surgery consisted primarily of gastric bypass (66.8% laparoscopic, 8.6% open), followed by laparoscopic gastric banding (23.8%). In 2012, there was a precipitous increase in use of laparoscopic sleeve gastrectomy (36.3 %), with a concurrent reduction in the use of laparoscopic (56.4%) and open (3.2%) gastric bypass, and a major reduction in laparoscopic gastric banding (4.1%).

J Am Coll Surg. 2012;doi: 10.1016/j.jamcollsurg.2012.10.003.







Laparoscopic total gastrectomy with D2 dissection increases the operative risk

This study compared short-term surgical outcomes between laparoscopic total gastrectomy (LTG, n=122) and open total gastrectomy (OTG, n=122) using the propensity score matching method using the covariates of age, sex, body mass index, comorbidity, American Society of Anesthesiologists (ASA) score, operators, and tumor stage. The LTG group showed significantly longer operating time, but postoperative outcomes, including hospital stay, morbidity, and mortality, were similar in the 2 groups. In the subgroup with D2 lymph node dissection, the LTG group showed significantly increased morbidity (52.6% vs 21.0%) and tendency toward increased length of hospital stay and mortality as compared with the OTG group.

J Am Coll Surg, 2012;doi: 10.1016/j.jamcollsurg.2012.10.014.



Pathologically complete response after neoadjuvant chemorad in oesophageal cancer is not synonymous with cure

This study was performed to determine the pattern of recurrence in oesophageal cancer patients with a pathologically complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) followed by surgery (n=188). pCR was achieved in 33%. Recurrence developed in 39% with a pCR and 56% without a pCR. The overall 5-year survival rate was significantly higher in the pCR group than in the non-pCR group (52 v 34%).

Br J Surg, 2012;doi:10.1002/bjs.8968.



Hospitals performing large numbers of oesophagogastric cancer resections have lower 30-day mortality rate

The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between in the Netherlands, Sweden, Denmark and England. Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates were higher in the Netherlands and Denmark compared to England. The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden. Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy and gastrectomy.

Br J Surg. 2013 Jan;100(1):83-94.






LMWH is more effective than other strategies in the prevention of postop VTE following bariatric surgery

Using the Michigan Bariatric Surgery Collaborative, the authors evaluated the effectiveness and safety of 3 predominant venous thromboembolism (VTE) prophylaxis strategies among patients undergoing bariatric surgery. Unfractionated heparin preoperatively and postoperatively (UF/UF), UF heparin preoperatively and low-molecular-weight heparin postoperatively (UF/LMW), and LMW heparin preoperatively and postoperatively (LMW/LMW) were compared in 24,777. Overall, adjusted rates of VTE were significantly lower for the LMW/LMW and UF/LMW treatment groups compared with the UF/UF group.  LMW/LMW seemed more effective for high-risk patients. There were no significant differences in rates of hemorrhage or serious hemorrhage among the treatment strategies.

Arch Surg. 2012;147(11):994-998.



Working with fixed teams in bariatric surgery reduced procedure duration and improved teamwork and safety

The authors studied the effects on patient outcomes, teamwork and safety climate, and procedure durations resulting from working with operating room (OR) teams that remain fixed for the day instead of OR teams that vary during the day. Patient outcomes did not appear to worsen using either system, however, teamwork and safety climate (both measured on a 5-point scale) improved significantly when teams were fixed. In addition, procedures were performed significantly faster. This appeared to be mainly realized for surgical time.



Laparoscopic surgery in obese patients reduces surgical site infection rate by 70%-80%

This meta-analysis compared surgical site infections rate in obese patients after laparoscopic surgery with open general abdominal surgery. 8 RCTs and 36 observational studies on bariatric and nonbariatric surgery were identified. Meta-analyses of RCTs and observational studies showed a significantly lower surgical site infection rate after laparoscopic surgery (OR = 0.19; 95% CI [0.08-0.45]. No publication bias was present for the observational studies.

Ann Surg, 2012;256(6):934-45.








Smoothened inhibitor prevents the development of Barretts and esophageal adenocarcinoma in vivo

This group studied the effect of Hedgehog (Hh) pathway blockade with smoothened (Smo) inhibitor on the development of Barretts oesphagus (BE) / esophageal adenocarcinoma (EAC) in the Levrat model in which induced gastroduodenoesophageal reflux (GDER) leads to esophageal carcinogenesis. mRNA expression of Indian Hh, a ligand of transmembrane receptor patched 1, was 184× higher in BE and 99× higher in EAC compared with normal esophageal tissue. Compared with controls, the incidence of BE and EAC was decreased in treated animals by 35.7% and 36% respectively. Compared with untreated EAC, Ki-67 was downregulated and cleaved caspase 3 was no different in treated EAC.

Annals of Surgery, October 2012; doi: 10.1097/SLA.0b013e318270500d



Preop ambulatory 24-h pH monitoring should be performed in patients suspected of having GERD

The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for anti-reflux surgery (ARS). Patients were divided based on the presence or absence of gastroesophageal reflux on pH monitoring: GERD+ (n = 78, 58 %) and GERD- (n = 56, 42 %). There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 47 % had reflux and 53 % had no reflux at the esophagogram compared with 30 % and 70 % respectively in the GERD- patients. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD- patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.

Journal of Gastrointestinal Surgery, 2012;DOI:10.1007/s11605-012-2057-5



Electrical stimulation of the lower esophageal sphincter stimulation is effective for treating GERD

The aim of this open-label pilot trial was to evaluate the safety and efficacy of long-term lower esophageal sphincter (LES) stimulation using a permanently implanted LES stimulator in patients with gastroesophageal reflux disease (GERD). Bipolar stitch electrodes were placed in the LES of 24 patients (mean age = 53 years, SD = 12 years; 14 men); 23 completed their 6-month evaluation. Median GERD-HRQL scores at 6 months were significantly better than both baseline on-PPI and off-PPI. Median esophageal pH < 4.0 improved and at 6-months, 91 % were off PPI. There were no adverse events or untoward sensation due to stimulation.

Surgical Endoscopy, 2012;DOI:10.1007/s00464-012-2561-4






Surgical compared with non-surgical treatment of oesophagogastric cancer is associated with better survival

The retrospective Dutch population-based study investigated the association between patient characteristics, resection rates and survival among patients with oesophageal or gastric cancer. The database contained information on 923 patients with oesophageal squamous cell carcinoma, 1181 with distal oesophageal, 942 with cardia and 3177 with subcardia cancer. Of patients with TNM stage I-III disease, 20·8 per cent (557 of 2680 patients) did not undergo resection. Age >70 years was associated with a lower likelihood of resection for distal oesophageal and gastric cancer. The 30-day mortality rate increased with age and co-morbidity. Surgery (compared with no surgery) was independently associated with better survival for all tumour types.

Br J Surg. 2012 Dec;99(12):1693-700.



Gastric cancer patients with preop lymph nodes measuring >15 mm have worse long-term outcomes

This study attempts to determine an appropriate nodal size cut-off value in patients with gastric cancer to predict pathological nodal status on CT. A cutoff value of 15 mm was found to be appropriate for grouping patients into large (≥15 mm) and small (<15 mm) lymph node metastasis (LLNM and SLNM) groups, with a high PPV (98.6 %) and specificity (99.8 %). In the LLNM group, the 5-year survival rate was 55 % compared to 73.2 % in the SLNM group. After stratification by tumor depth, the same trend was observed in patients with pT3 disease and those with pT4 disease.

Ann Surg Oncol, 2012;DOI: 10.1245/s10434-012-2699-2



Loss in body weight and nutritional status are similar after Billroth I and Roux-en-Y reconstruction following distal gastrectomy

This randomized, controlled trial evaluated the clinical efficacy of Billroth I (BI, n=163) and Roux-en-Y (RY, n=169) reconstruction at 1 year after distal gastrectomy for gastric cancer. Loss in body weight or nutritional status at 1 year after surgery did not differ significantly between the groups. Endoscopic examination at 1 year showed reflux esophagitis and remnant gastritis was more prevelant following BI compared to RY group.

Ann Surg Oncol, 2012; 2012, DOI: 10.1245/s10434-012-2704-9







Risk calculator to predict 30-day postoperative mortality after bariatric surgery

The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. A review was conducted using NSQIP Data from 2006-2008 of patients undergoing bariatric surgeries (with the exception of sleeve gastrectomy).  Of 21,891 patients, 30 day mortality was 0.14% and morbidity 5.5%.  Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets. 

Journal of the American College of Surgeons 2012;212(6):892-899.




Advanced age is a risk factor for complications and mortality after bariatric surgery

This retrospective study analyzed the effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP). A total of 489 patients entered the study and preoperatively, the younger group showed a significantly higher BMI. Younger patients had a significantly greater and prolonged BMI decrease during the entire follow-up period.

Ann Surg 2012 Nov;256(5):724-9.




Obese patients get inadequate care after bariatric surgery

The National Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of 381 patients who had bariatric surgery in the UK (223 cases on the NHS and 173 cases in the private hospitals). They found that 28% and 61% had no input from a psychologist before surgery. 14% hospitals undertook weight loss surgery on patients who did not meet guidance set out by the National Institute for Health and Clinical Excellence and consent forms did not contain appropriate information in 24% of cases. In the postoperative period, 44% had their first follow-up appointment >six weeks after discharge with a lack of involvement of dietitians and clinicians in the follow-up appointment. Readmission rates within six months were high at 18%.



The Role of Radiation Therapy in Resected T2 N0 Esophageal Cancer: A Population-Based Analysis

This population-based study, spanning 10 years, examined overall survival (OS) after resection of T2N0 esophageal cancer, with or without radiation therapy. 490 patients undergoing resection of the mid / distal esophagus for T2N0 disease (squamous cell or adenocarcinoma) were identified from a cancer registry (1998-2008). The 5-year cancer-specific survival (CSS) and OS after resection with or without radiation therapy were compared. The 5-year OS was 38.6% (95% CI, 31.7% to 45.5%) in patients undergoing resection alone and 42.3% (95% CI, 34.7% to 49.6%) for combined therapy (p = 0.48). There was no difference in OS after risk adjustment (hazard ratio [HR], 1.14; 95% CI, 0.87 to 1.48; p = 0.35). No difference in CSS was detected (HR, 1.16; 95% CI, 0.98 to 1.39, p = 0.09). The addition of radiotherapy with esophageal resection did not increase either OS or CSS compared with resection alone.

Ann Thor Surg 2012; doi: 10.1016/j.athoracsur.2012.08.049



Ethnicity in relation to incidence of oesophageal and gastric cancer in England

This study investigated the incidence of oesophageal and gastric cancer between ethnic groups. Data on all oesophageal and gastric cancer patients (2001 and 2007) in England were analysed. Male and female age-standardised incidence rate ratios (IRRs) were calculated for each ethnic group, using white Caucasians as the references. Complete data was available on 76,130 patients. White men had the highest incidence of oesophageal cancer (especially lower oesophageal and gastric cardia). Compared with White women, Bangladeshi women (IRR 2.02 (1.24–3.29)) had a higher incidence of oesophageal cancer (especially upper- and mid-oesophageal). In contrast Black Caribbean men (1.39 (1.22–1.60)) and women (1.57 (1.28–1.92)) had a higher incidence of gastric cancer compared with their White counterparts. Such marked ethnic differences in the incidence of upper GI cancer require further research to identify why variation exists. 

Br J Cancer 2012; doi:10.1038/bjc.2012.465



Gastrectomy for Early Gastric Cancer is Associated with Decreased Cardiovascular Mortality in Association with Postsurgical Metabolic Changes

This prospective Korean study investigated cardiovascular and all-cause mortality in patients undergoing gastrectomy for early gastric cancer (n=2,477), including analysis of changes in metabolic parameters (n=51). Standardised mortality ratios (SMR) were calculated using sex- and age-matched mortality in the general population. 244 deaths occurred during follow up and all cause mortality was not different to that of the general population (SMT=1.01 [0.89-1.14]). Cardiovascular mortality, however, was significantly lower (SMR = 0.35 [0.22 − 0.53]). Significant reductions in both body weight and visceral fat occurred post-operatively. Triglycerides, LDL-cholesterol, and plasminogen activator inhibitor-1 levels were significantly decreased, whereas HDL-cholesterol and adiponectin levels were increased. Carotid intima-media thickness was also significantly decreased in previously obese and nonobese patients. Patients with early gastric cancer, undergoing gastrectomy, have a lower cardiovascular mortality. Similar to patients undergoing bariatric surgery, a reduction in both body weight and visceral fat may improve impaired lipid metabolism and prevent atherosclerotic changes.

Ann Surg Oncol, 2012; DOI:10.1245/s10434-012-2688-5




Surgical stress after robot-assisted distal gastrectomy and its economic implications

The aim of this prospective study was to compare the surgical stress response and costs of robot-assisted distal gastrectomy (RADG, n=30) with those of laparoscopy-assisted distal gastrectomy (LADG, n=120). Median duration of operation was longer (218 vs. 140 min) and costs were much higher, but postoperative abdominal drain production was less and postoperative performance status was worse in the RADG group. CRP and IL 6 levels on day 3 were lower in the LADG group.

Br J Surg. 2012;99(11):1554-1561.



Effects of hybrid minimally invasive oesophagectomy on major postoperative pulmonary complications

The aim of this case matched study was to test the hypothesis that hybrid minimally invasive oesophagectomy (HMIO) decreases the 30-day major postop pulmonary complications (MPPC) rate without compromising oncological outcomes. MPPCs at 30 days were significantly less frequent after HMIO compared with open surgery as were in-hospital mortality and overall morbidity. In multivariable analysis HMIO was independently protective against acute respiratory distress syndrome (ARDS). Lymph node yields and survival were similar in the two groups.

Br J Surg 2012;99(11):1547-1553.



Health care use during 20 years following bariatric surgery

Using the ongoing, prospective Swedish Obese Subjects study, the authors assessed health care use over 20 years by obese patients treated conventionally or with bariatric surgery. Of the surgery patients, 13% underwent gastric bypass, 19% gastric banding, and 68% vertical-banded gastroplasty, while the controls received conventional obesity treatment. During the years 2 through 6, surgery patients had an accumulated annual mean of 1.7 hospital days vs 1.2 days among control patients. From year 7 to 20, both groups had a mean annual 1.8 hospital days. From year 7 to 20, the surgery group incurred a mean annual drug cost of US $930; the control patients, $1123.

JAMA. 2012 Sep 19;308(11):1132-41.




A Study Examining the Complications Associated with Gastric Banding

This single centre study examines the long-term complication rate of 1,100 laparoscopic adjustable gastric banding operations. A total of 932 females and 147 males underwent gastric banding. 13.2 % patients experienced band slippage and eighty-two patients had their band removed due to complications; there was slippage in 60, erosion in 17, and band intolerance in 5. 12.6 % patients experienced problems with their port or port tubing. One postoperative death was due to biliary peritonitis in a patient who had undergone simultaneous cholecystectomy.

Obesity Surgery 2012;DOI:10.1007/s11695-012-0760-7



Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial

RCT to study to determine whether surgically induced weight loss is more effective than conventional weight loss therapy in the management of Obstructive sleep apnea (OSA). Mean weight loss was 5.1 kg in the conventional weight loss program compared with 27.8 kg in the bariatric surgery group. The apnea-hypopnea index (AHI) decreased by 14.0 events/hour in the conventional weight loss group and by 25.5 events/hour in the bariatric surgery group; however, this was not significant. CPAP adherence did not differ between the groups.

JAMA. 2012;308(11):1142-9.



Health benefits of gastric bypass surgery after 6 years

A prospective study to examine the association of Roux-en-Y gastric bypass (RYGB) surgery with weight loss, diabetes mellitus, and other health risks 6 years after surgery. Six years after surgery, patients who received RYGB surgery lost 27.7% of their initial body weight compared with 0.2% gain in control group 1 (sought but did not have surgery) and 0% in control group 2 (randomly selected from a population-based sample not seeking weight loss surgery). Weight loss maintenance was superior in patients who received RYGB surgery. Diabetes remission rates were 62% after surgery, 8% in control group 1 and 6% in control group 2. The numbers of participants with bariatric surgery-related hospitalizations were 7.9%, 3.9% and 2.0% for the RYGB surgery group and 2 control groups, respectively.

JAMA. 2012;308(11):1122-31.




Impact of Obesity on Perioperative Complications and Long-term Survival of Patients with Gastric Cancer

The aim of this retrospective study was to evaluate the effects of being overweight on surgical and long-term outcomes for patients with gastric cancer. 60.7 % of the study population were overweight and had more proximal tumors and a lower T stage. A BMI of ≥25 was associated with increased postoperative complications including wound infections and anastomotic leaks. Multivariate logistic regression analysis showed that higher BMI, total gastrectomy, and use of neoadjuvant chemotherapy were associated with increased wound infection and anastomotic leak. Overweight patients were less likely to have adequate lymph node staging. However, there was no difference in overall survival or disease-specific survival between the two groups.

Ann Surg Oncol. 2012 Sep 14. [Epub ahead of print]



Long-Term Effects of Sleeve Gastrectomy and Roux-en Y Gastric Bypass Surgery on Type 2 Diabetes Mellitus in Morbidly Obese Subjects

The aim of the study was to identify the rates and the predictors of long-term remission and the recurrence of type 2 diabetes mellitus (T2DM) after Roux-en-Ygastric bypass (RYGBP) or sleeve gastrectomy (SG). 75.2% of subjects presented with remission of T2DM lasting at least 12 months. Regression analysis showed a longer history of T2DM, a higher presurgical glycated hemoglobin level and insulin treatment at baseline as independent predictors for the lack of T2DM remission. Insulin use before surgery, an older age, and weight regain after remission predicted recurrence of the disease.

Annals of Surgery 2012;doi: 10.1097/SLA.0b013e318262ee6b



Proposal for a Multifactorial Prognostic Score That Accurately Classifies 3 Groups of Gastric Carcinoma Patients With Different Outcomes After Neoadjuvant Chemotherapy and Surgery

The authors developed a multifactorial histopathological prognostic score (PRSC) for patients with gastric cancer treated with neoadjuvant chemotherapy before surgery for the accurate discrimination of patient subgroups with differing outcomes. The PRSC showed a clear discrimination of 3 significantly different prognostic groups (group A: 76 patients; group B: 210 patients; group C: 142 patients; P < 0.001). In multivariate analyses, including the completeness of resection, tumor diameter, lymphatic vessel invasion, tumor grading, and Lauren classification, the PRSC was the only independent prognostic factor for overall survival.

Annals of Surgery 2012;doi: 10.1097/SLA.0b013e318262a591



Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

This retrospective study reports a laparoscopic, prosthesis-free technique to repair of giant hiatus hernia (GHH) defined as >30 % intrathoracic stomach within the thoracic cavity. Surgery was conducted in 100 patients (70F, 30 M). Median stay was 2.5 days. One postoperative death occurred secondary to respiratory sepsis and 8 % patients had perioperative complications. 2 % had symptomatic recurrence of their hiatus hernia and another 7 % had small asymptomatic recurrences at 6 months. 2 % required revisional surgery. Quality of life significantly improved postoperatively.

Surg Endosc 2012;DOI:10.1007/s00464-012-2501-3



Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects

In an analysis of Swedish obesity Study data the investigators examined the effects of bariatric surgery on the prevention of type 2 diabetes. 1658 patients who underwent bariatric surgery and 1771 obese matched controls were included. None of the participants had diabetes at baseline. Patients in the bariatric-surgery cohort underwent banding (19%), vertical banded gastroplasty (69%), or gastric bypass (12%). During the 15 year follow-up period, the incidence of type 2 diabetes was 28.4 cases per 1000 person-years and 6.8 cases per 1000 person-years in the control and operated group respectively. The postoperative mortality was 0.2%.

N Engl J Med 2012;23;367(8):695-704.



Centralisation of upper GI cancer services

The aim of this study was to assess whether patients diagnosed with oesophageal or gastric cancer at a local district general hospital (DGH) have a similar temporal pathway through the decision-making and treatment process compared to those patients presenting at the centralised, tertiary hospital. There was a significant increase in the time from diagnosis to multidisciplinary discussion if patients presented at the DGH compared to the tertiary centre (13.3 days vs. 25.67 days). However, time to first treatment  was longer at the tertiary centre versus the DGH (43.4 days vs. 25.5 days).



Development and validation of a bariatric surgery mortality risk calculator

The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. The National Surgical Quality Improvement Program (NSQIP) dataset (2006 to 2008) identified nearly 33,000 patients undergoing bariatric surgery for morbid obesity. This cohort was divided into training and validation datasets. Multiple logistic regression analysis was performed on the training dataset. Thirty-day mortality was 0.14%. Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets. The risk model was used to develop an interactive risk calculator.

J Am Coll Surg 2012;214(6):892-900



Long-term follow-up of malignancy biomarkers in patients with Barrett's esophagus undergoing medical or surgical treatment

This study aimed to compare validated biomarkers of malignancy between 2 groups of patients with Barrett's esophagus (BE) undergoing medical or surgical treatment. 20 patients were given 40 mg/day of proton pump inhibitors (PPIs) and 25 underwent Nissen fundoplication (NFP). After a median follow-up of 8 years (range, 5-10 years), the values of Ki-67, p53, and apoptosis were analyzed in all patients before treatment and then at 1, 3 and 5 years. Both Ki-67 and p53 remained stable after NFP, whereas they increased progressively in patients under PPIs. The apoptotic index increased progressively after NFP and decreased in the patients under PPIs with significant differences at 3 and 5 years of follow-up. On comparing the subgroups of successful treatment the same differences were found.

Ann Surg. 2012;255(5):916-21.



Safety and activity of anti-PD-L1 antibody in patients with advanced cancer

Programmed death 1 (PD-1) protein, a T-cell coinhibitory receptor, and one of its ligands (PD-L1) play a pivotal role in the ability of tumor cells to evade the host's immune system. Blockade of interactions between PD-1 and PD-L1 enhances immune function in vitro and mediates antitumor activity in preclinical models. This multicenter phase 1 trial published in NEJM studied the effect of escalating doses of IV anti-PD-L1 antibody to patients with selected advanced cancers. A total of 207 patients--75 with non-small-cell lung cancer, 55 with melanoma, 18 with colorectal cancer, 17 with renal-cell cancer, 17 with ovarian cancer, 14 with pancreatic cancer, 7 with gastric cancer, and 4 with breast cancer--had received anti-PD-L1 antibody. The median duration of therapy was 12 weeks and an objective response (complete or partial) was observed in 9 of 52 patients with melanoma, 2 of 17 with renal-cell cancer, 5 of 49 with non-small-cell lung cancer, and 1 of 17 with ovarian cancer. Responses lasted for 1 year or more in 8 of 16 patients with at least 1 year of follow-up.

N Engl J Med 2012;366(26):2455-65



Preoperative chemoradiotherapy for esophageal or junctional cancer

This RCT published in the NEJM compared chemoradiotherapy followed by surgery with surgery alone in this patient population. 366 patients were enrolled: 275 (75%) had adenocarcinoma, 84 (23%) had squamous-cell carcinoma, and 7 (2%) had large-cell undifferentiated carcinoma. Of the 366 patients, 178 were randomly assigned to chemoradiotherapy followed by surgery, and 188 to surgery alone. Complete resection with no tumor within 1 mm of the resection margins (R0) was achieved in 92% of patients in the chemoradiotherapy-surgery group versus 69% in the surgery group. A pathological complete response was achieved in 47 of 161 patients (29%) who underwent resection after chemoradiotherapy. Postoperative complications were similar in the two treatment groups, and in-hospital mortality was 4% in both. Median overall survival was 49.4 months in the chemoradiotherapy-surgery group versus 24.0 months in the surgery group.

N Engl J Med. 2012 May 31;366(22):2074-84



Laparoscopic Sleeve Gastrectomy for Super Obese Patients: Forty-eight Percent Excess Weight Loss After 6 to 8 Years With 93% Follow-Up

In this study, the authors report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25-78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38-95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m(43-90) to 46 kg/m (22-73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease.

Ann Surg 2012;256(2):262-5



Complications and nutrient deficiencies two years after sleeve gastrectomy

The aim of this study was to investigate patient outcomes and nutritional deficiencies following sleeve gastrectomy (SG) during a median follow-up of two years. 100 patients (female: male = 59:41) with a mean age of 43.6 years (range: 22-64) and a preoperative BMI of 52.3 kg/m^2 (range: 36-77) underwent SG. The mean operative time was 86.4 min (range: 35-275). Major complications were observed in 8.0 % of the patients, with 1 death. Out of the total 100 patients, 48 % were supplemented with iron, 33 % with zinc, 34 % with a combination of calcium carbonate and cholecalciferol, 24 % with vitamin D, 42 % with vitamin B12 and 40 % with folic acid. The patients who received only a SG (n = 75) had %EWL of 53.6, 65.8 and 62.6 % after 6, 12 and 24 months, respectively.

BMC Surgery 2012;12:13



Outcomes of Bariatric Surgery Performed at Accredited vs Non-accredited Centers

The aim of this study was to analyze the perioperative outcomes of bariatric surgery performed at accredited vs non-accredited centers (based on volume). Of the 35,284 bariatric operations performed during the study period, 89.2% of cases were performed at 71 accredited centers; 10.8% of cases were performed at 43 non-accredited centers. The rate of in-hospital mortality was significantly lower in accredited centers (0.06% vs 0.21%). Compared with nonaccredited centers, bariatric surgery performed at accredited centers was also associated with shorter length of stay (mean difference 0.3 days; 95% CI 0.16 to 0.44) and lower cost (mean difference, $3,758; 95% CI, $2,965 to $3,952). Post-hoc analyses based on procedural type and severity of illness suggested possible associations between center accreditation and improved in-hospital mortality in patients who underwent gastric bypass and patients with higher severity of illness; similarly, patients requiring prolonged ICU or hospital stay (≥7 days) had significantly lower in-hospital mortality within accredited centers.

Journal of the American College of Surgeons 2012;doi:10.1016/j.jamcollsurg.2012.05.032



Prevalence of alcohol use disorders before and after bariatric surgery

This study aimed to determine the prevalence of pre- and post-operative alcohol use disorders (AUD) and independent predictors of postoperative AUD. A prospective cohort study  of adults who underwent bariatric surgery at 10 US hospitals. 2458 participants were included. The prevalence of AUD symptoms did not significantly differ from 1 year before to 1 year after bariatric surgery (7.6% vs 7.3%; P = .98), but was significantly higher in the second postoperative year (9.6%). The following preoperative variables were independently related to an increased odds of AUD after bariatric surgery: male sex, younger age, smoking, regular alcohol consumption, recreational drug use, lower sense of belonging and undergoing a Roux-en-Y gastric bypass procedure.

JAMA. 2012;307(23):2516-2525


Diverging trends in recent population-based survival rates in oesophageal and gastric cancer

Survival trends in oesophageal and gastric cancer were investigated using a nationwide Swedish population-based study. The relative survival rates in oesophageal and gastric cardia adenocarcinoma have improved since the 1990s, but not in oesophageal squamous cell carcinoma or gastric non-cardia adenocarcinoma. The relative 5-year survival rates during the two recent periods 1990-1999 and 2000-2008 were 12.5% and 10.3% for oesophageal squamous cell carcinoma, 12.5% and 14.6% for oesophageal adenocarcinoma, 11.1% and 14.3% for gastric cardia adenocarcinoma, and 20.2% and 19.0% for gastric non-cardia adenocarcinoma. The 3-year survival in tumour stage III in 2004-2008 was about 25% for all four tumour types.

PLoS One 2012;7(7):e41352



Impact of jejunal pouch interposition reconstruction after proximal gastrectomy for early gastric cancer on quality of life: short- and long-term consequences

Proximal gastrectomy with jejunal pouch interposition (JPI) reconstruction is advocated as a function-preserving surgery in patients with early gastric cancer located in the upper third of the stomach. This study investigates 22 patients who underwent JPI reconstruction and 22 patients who underwent Roux-en-Y (RY) reconstruction after total gastrectomy for stage IA/IB gastric cancer. Morbidity, nutritional parameters and body weight were no different between the 2 groups. JPI patients had better quality of life at 1 year but no difference at 5 years after the surgery.

Am J Surg 2012;204(2):203-9



Postoperative Bleeding Complications after Gastric Cancer Surgery in Patients Receiving Anticoagulation and/or Antiplatelet Agents

This study evaluated postoperative bleeding and thromboembolic complications after radical gastrectomy in patients undergoing perioperative antithrombotic treatment. During the study period, 340 patients underwent radical gastrectomy. The group who had perioperative antithrombotic treatment (n=62) had a significantly higher postoperative bleeding rate (8.1 vs. 0.7 %). Multivariate analysis revealed that perioperative antithrombotic treatment was the only independent risk factor of postoperative bleeding complications after radical gastrectomy (odds ratio, 8.53). Perioperative antithrombotic treatment is an independent risk factor of postoperative bleeding complications in patients with gastric cancer undergoing radical gastrectomy. However, such treatment was effective in preventing postoperative thromboembolic events.



Comparison of 30day, 90day and inhospital postoperative mortality for eight different cancer types

This study was evaluated the impact of using different definitions of postoperative mortality for several types of cancer surgery. Populationbased data for the period 1997–2008 were retrieved from the Rotterdam Cancer Registry and postoperative deaths were tabulated as 30day, inhospital or 90day mortality. 40 474 patients were included. Thirtyday mortality rates were highest after gastric (8·8 per cent) and colonic (6·0 per cent) surgery, and lowest after breast (0·2 per cent) and renal (2·0 per cent) procedures. For most tumour types, the difference between 30day and inhospital rates was less than 1 per cent. However, for bladder and oesophageal cancer, inhospital mortality rate was considerably higher at 5·1 per cent (+1·3 per cent) and 7·3 per cent (+2·8 per cent) respectively. From this study, the 30day definition is recommended as an international standard because it includes the great majority of surgeryrelated deaths and is not subject to discharge procedures.

BJS 2012; DOI: 10.1002/bjs.8813





Prognostic importance of the inflammation-based Glasgow prognostic score in patients with gastric cancer

The inflammation-based Glasgow prognostic score (GPS) has been shown to be a prognostic factor for a variety of tumours. This study published in the British Journal of Cancer investigates the significance of the modified GPS (mGPS) for the prognosis of patients with gastric cancer. The mGPS (0=C-reactive protein (CRP) <10mgl−1, 1=CRP>10mgl−1 and 2=CRP>10mgl−1 and albumin<35gl−1) was calculated on the basis of preoperative data for 1710 patients with gastric cancer. Patients were given an mGPS of 0, 1 or 2. The prognostic significance was analysed by univariate and multivariate analyses. Increased mGPS was associated with male patient, old age, low body mass index, increased white cell count and neutrophils, elevated carcinoembryonic antigen and CA19-9 and advanced tumour stage. Kaplan–Meier analysis and log-rank test revealed that a higher mGPS predicted a higher risk of postoperative mortality in both relative early-stage (stage I; P<0.001) and advanced-stage cancer (stage II, III and IV; P<0.001). Multivariate analysis demonstrated the mGPS to be a risk factor for postoperative mortality (odds ratio 1.845; 95% confidence interval 1.184–2.875; P=0.007). The preoperative mGPS is a simple and useful prognostic factor for postoperative survival in patients with gastric cancer.

British Journal of Cancer 2012;doi:10.1038/bjc.2012.262



Safety, efficacy, and long-term outcomes for endoscopic submucosal dissection of early esophagogastric junction cancer

Early esophagogastric junction (EGJ) cancer is currently being treated by endoscopic submucosal dissection (ESD), but long-term outcomes are still unknown. The aim of this study published in Gastric Cancer was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases. Forty-four cases of early EGJ cancer were treated by ESD. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative cases. ESD is a safe and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion, ESD is an acceptable treatment option. It is also suitable for diagnostic purposes in evaluating the need for surgery.

Gastric Cancer 2012;doi:10.1007/s10120-012-0162-5



Low impact of staging EUS for determining surgical resectability in esophageal cancer

EUS has a high sensitivity and specificity for T and N staging, the value of EUS for staging tumors as resectable or non-resectable after CT of the chest and abdomen and US neck assessment, is largely unknown. This study published in Surgical Endosccopy  assessed the diagnostic value of EUS for determining resectability of esophageal cancer. A retrospective analysis of all consecutive patients with esophageal carcinoma who underwent staging EUS, CT, and US were included. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of CT/US neck and CT/US neck + EUS for predicting surgical resectability were calculated. PPVs of CT/US alone and CT/US + EUS together were compared for assessing the diagnostic value of EUS. 211 patients were included, of which 176 underwent all three staging investigations. Based on preoperative staging, 173 (82 %) patients were considered resectable and 38 (18 %) nonresectable. Of the 173 initially resectable patients, 145 were operated on. Of these patients, five (3.4 %) tumors were non-resectable during surgery. Postoperative sensitivity, specificity, PPV, and NPV of CT/US and CT/US + EUS for predicting surgical resectability were 88 vs. 87 %, 20 vs. 40 %, 97 vs. 98 %, and 6 vs. 10 %, respectively. Based on this study, although EUS adds to the specificity of preoperative esophageal cancer staging the overall added value of EUS seems to be limited.

Surgical Endoscopy 2012;doi:10.1007/s00464-012-2254-z



Laparoendoscopic single-site gastric bands versus standard multiport gastric bands: a comparison of technical learning curve measured by surgical time

The authors describe their initial experience of laparoendoscopic single-site (LESS) gastric band insertion for morbid obesity and compare technical results with those of standard multi-port techniques. They perform the LESS approach using a multichannel port and reticulating instruments or non-disposable curved instruments and a separate 2mm sub-xiphoid stab incision to insert a Mini-Lap liver retractor. The multi-port approach utilises three 5mm trocars and one 15mm trocar as well as a Nathanson liver retractor. All surgeries were performed by a single surgeon and results from his first fifty multi-port band procedures (taken to represent his initial banding experience) were compared with his first 48 LESS band procedures. Demographics of the patients, surgical times, complications and 3-month excess weight loss were compared between the groups by interrogating a retrospective analysis of prospectively collected data from all patients who underwent gastric band insertion at their institution. The mean BMI for the LESS group was significantly lower than that of the standard multi-port approach group: 43.19 kg/cm2 (range, 35.8 – 56.3) for the LESS cohort compared with 48.3 kg/cm2 (range, 37 – 64.1) for the multi-port cohort (P<0.001). The average surgical time was longer for the LESS cohort (76.85 minutes versus 64.4 minutes, P=0.0015) although a significant decrease in time was found between the first 24 LESS patients and the second 24 LESS patients. There was no statistically significant difference in excess weight loss and there were no complications or conversion to laparoscopy or laparotomy. Hiatal hernia repair was required in 14.8% of LESS patients and 10% of multi-port approach patients. The authors rightly conclude that this study does demonstrate a learning curve with a single-port technique and that in experienced hands, it is safe and feasible. Although there was a statistical difference in operating time, it was only just over 10 minutes. However, the surgeon had already developed significant experience in the laparoscopic gastric band procedure before attempting single-port surgery and as such the technique may not be advisable for surgeons at the start of an obesity surgery practice. Further, the BMI was lower in the LESS group and this was a planned inclusion criteria protocol and the authors report that they selected interested patients who tended to have a lower BMI. Whether the technique is safe in less experienced hands and whether there are definitive benefits (weight loss, pain, hospital stay, complications) with a single-port technique remain to be seen and the authors admit that long term data are needed to prove that LESS is as good as standard multi-port laparoscopic surgery.

Am J Surg 2012;203(3):327-9 


Impact of anastomotic complications on outcome after laparoscopic gastrectomy for early gastric cancer

The authors aimed to assess the effect of anastomotic complications (leak, stricture, remnant gastric stasis) on long-term survival after laparoscopically assisted gastrectomy (LAG) for early gastric cancer (EGC) and further to determine which factors might contribute to such complications. Results from prospective identification of anastomotic complications for 400 consecutive patients who underwent LAG for EGC (T1 gastric adenocarcinoma) from 1997 to 2008 are detailed. Anastomotic complications occurred in 37 patients (9.3%) including leakage (14 patients), stricture (11 patients) and remnant gastric stasis (14 patients). Overall 5-year survival was 92.9% (median survival, 62 months) and there was a significant survival difference between patients in favour of those without anastomotic complications (94.2% versus 81%, P=0.009). The only predictive factor for anastomotic complications was early surgical experience (first 50 cases). The authors highlight the potential devastating impact of anastomotic complications on mortality for a disease that has very high survival rates and advocate meticulous technique and experienced assistance as the surgeon develops familiarity with the laparoscopic techniques involved. For new consultants of the future, this seems to stress the importance of good senior support and mentoring when appointed.

BJS 2012;99:849-854



Reporting of short-term clinical outcomes after esophagectomy: a systematic review

The incidence of oesophageal cancer has risen steadily over the last two decades. Despite the increasing utilisation of multimodal therapy, surgery remains the mainstay of curative treatment and though results after oesophagectomy are improving, oesophagectomy is still associated with major complications. The authors highlight the importance of accurate measurement and reporting of complications to allow comparison between surgeons and hospitals. They performed a systematic review of reports of complications after oesophagectomy between 2005 and 2009 and aimed to assess the quality and consistency of reporting of complications. Of 3458 abstracts, 122 papers were included in the review reporting outcomes in 57,299 oesophagectomies. There were wide variations in outcome reporting including 6 different interpretations of  post-operative death, 22 different descriptions of anastomotic leak and no single complication reported in all papers. Over 60% of papers did not define their measured complications. They conclude that current reporting of short-term outcomes after oesophagectomy is inconsistent and suggest that mortality and morbidity reporting should be standardised to make cross-study comparisons possible and meaningful. Perhaps the key outcome measure after oesophagectomy is survival and they suggest 3-month death rate as a valuable marker which encompasses procedure-related death. 12-month survival is also important as it includes operative death and early recurrence. Although such recommendations are important and the development of a core set of outcomes after oesophagectomy would improve reporting of complications, it is difficult to ascertain which body would be responsible for developing these outcomes.

Ann Surg 2012;255:658-66



Weight Loss and Metabolic Improvement in Morbidly Obese Subjects Implanted for 1 Year With an Endoscopic Duodenal-Jejunal Bypass Liner

The duodenal-jejunal bypass liner (DJBL) is an endoscopic implant that mimics the duodenal-jejunal bypass component of the Roux-en-Y gastric bypass. Reports have shown significant weight loss and improvement in type 2 diabetes for up to 6 months. The authors attempted to evaluate the safety, weight loss, and cardiometabolic changes in obese subjects implanted with the DJBL for 1 year. The DJBL was implanted endoscopically in 39 of 42 subjects (median age 36 years, 80% female, BMI: 43.7±5.9 kg/m2). Only 24/39 completed 52 weeks of follow-up. Three subjects could not be implanted due to short duodenal bulb. No procedure-related complications however there were 15 early endoscopic removals. At 52-week, total body weight change from baseline was −22.1±2.1 kg. Also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose were noted. The authors conclude DJBL is safe when implanted for 1 year and results in significant weight loss and improvements in cardiometabolic risk factors. However, nearly 40% of patients were unable to tolerate the device.

Annals of Surgery 2012;255:1080–1085



Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

The authors evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy using a randomized, nonblinded, single-center trial in 150 obese patients with uncontrolled type 2 diabetes. The mean age of the patients was 49 years, and 66% were women. The average pre-operative glycated hemoglobin level was 9.2±1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment. 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% in the medical-therapy group versus 42% in the gastric-bypass group and 37% in the sleeve-gastrectomy group. Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group and 6.6±1.0% in the sleeve-gastrectomy group. Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group than in the medical-therapy group. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. However, there were 4 patients underwent reoperations but no deaths or life-threatening complications. In patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. It will be interesting to evaluate these patients at longer time points to assess the durability of bariatric surgery in this group.

N Engl J Med 2012;366:1567-1576



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