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Thirty-Day Readmission After Radical Gastrectomy for Gastric Cancer: A Meta-analysis.
Dan, Z, YiNan, D, ZengXi, Y, XiChen, W, JieBin, P, LanNing, Y
The Journal of surgical research. 2019;:180-188
Abstract
BACKGROUND Readmission is a commonly accepted parameter to evaluate surgical quality, but previous studies reported inconsistent results in radical gastrectomy. The purpose of our study is to clarify the prevalence, potential causes, and risk factors of 30-d readmission after radical gastrectomy for gastric cancer. METHODS PubMed and Embase were systematically searched from inception to September 2018 for any possible inclusion. Prevalence, potential causes, and risk factors of 30-d readmission in included studies were extracted using a standardized EXCEL table. The overall 30-d readmission rate was pooled using a random-effects model. Odds ratios with 95% confidence intervals were used to estimate potential risk factors for 30-d readmission. Publication bias was assessed using a funnel plot and statistical tests. RESULTS A total of nine studies with 16,581 patients were included in the current meta-analysis. The pooled 30-d readmission rate after radical gastrectomy was 8% (95% confidence interval, 0.04-0.12). Nutritional difficulty and surgical site infections were the main causes for 30-d readmission. Cardiovascular comorbidity, total gastrectomy, nutritional risk screening 2002 score ≥3, any complications, laparoscopic gastrectomy, and C-reactive protein on postoperative day 3 ≥12 were strong predictors for 30-d readmission, whereas combined multiorgan resection was a weaker predictor. No significant publication bias was identified through the funnel plot and statistical tests. CONCLUSIONS The 30-d readmission rate after radical gastrectomy ranges from 4% to 12% and can mainly result from nutritional difficulty and surgical site infections. Nutritional risk screening 2002 score ≥3, cardiovascular comorbidity, total gastrectomy, any complications, and laparoscopic gastrectomy were potential risk factors for 30-d readmission.
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Mechanisms underlying the weight loss effects of RYGB and SG: similar, yet different.
Pucci, A, Batterham, RL
Journal of endocrinological investigation. 2019;(2):117-128
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Abstract
The worldwide obesity epidemic continues unabated, adversely impacting upon global health and economies. People with severe obesity suffer the greatest adverse health consequences with reduced life expectancy. Currently, bariatric surgery is the most effective treatment for people with severe obesity, resulting in marked sustained weight loss, improved obesity-associated comorbidities and reduced mortality. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), the most common bariatric procedures undertaken globally, engender weight loss and metabolic improvements by mechanisms other than restriction and malabsorption. It is now clear that a plethora of gastrointestinal (GI) tract-derived signals plays a critical role in energy and glucose regulation. SG and RYGB, which alter GI anatomy and nutrient flow, impact upon these GI signals ultimately leading to weight loss and metabolic improvements. However, whilst highly effective overall, at individual level, post-operative outcomes are highly variable, with a proportion of patients experiencing poor long-term weight loss outcome and gaining little health benefit. RYGB and SG are markedly different anatomically and thus differentially impact upon GI signalling and bodyweight regulation. Here, we review the mechanisms proposed to cause weight loss following RYGB and SG. We highlight similarities and differences between these two procedures with a focus on gut hormones, bile acids and gut microbiota. A greater understanding of these procedure-related mechanisms will allow surgical procedure choice to be tailored to the individual to maximise post-surgery health outcomes and will facilitate the discovery of non-surgical treatments for people with obesity.
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Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer.
Makuuchi, R, Irino, T, Tanizawa, Y, Bando, E, Kawamura, T, Terashima, M
Surgery today. 2019;(3):187-196
Abstract
Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.
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POSTOPERATIVE CHANGES IN INTESTINAL MICROBIOTA AND USE OF PROBIOTICS IN ROUX-EN-Y GASTRIC BYPASS AND SLEEVE VERTICAL GASTRECTOMY: AN INTEGRATIVE REVIEW.
Wagner, NRF, Zaparolli, MR, Cruz, MRR, Schieferdecker, MEM, Campos, ACL
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery. 2018;(4):e1400
Abstract
INTRODUCTION Studies suggest that weight loss induced by bariatric surgery and the remission of some comorbidities may be related to changes in the microbiota profile of individuals undergoing this procedure. In addition, there is evidence that manipulation of the intestinal microbiota may prove to be a therapeutic approach against obesity and metabolic diseases. OBJECTIVE To verify the changes that occur in the intestinal microbiota of patients undergoing bariatric surgery, and the impact of the usage of probiotics in this population. METHODS Articles published between 2007 and 2017 were searched in Medline, Lilacs and Pubmed with the headings: bariatric surgery, microbiota, microbiome and probiotics, in Portuguese, English and Spanish. Of the 166 articles found, only those studies in adults subjected to either Roux-en-Y gastric bypass or sleeve vertical gastrectomy published in original articles were enrolled. In the end, five studies on the change of intestinal microbiota composition, four on the indirect effects of those changes and three on the probiotics administration on this population were enrolled and characterized. CONCLUSION Bariatric surgery provides changes in intestinal microbiota, with a relative increase of the Bacteroidetes and Proteobacteria phyla and reduction of Firmicutes. This is possibly due to changes in the gastro-intestinal flux, coupled with a reduction in acidity, in addition to changes in eating habits. The usage of probiotics seems to reduce the gastro-intestinal symptoms in the post-surgery, favor the increase of vitamin B12 synthesis, as well as potentiate weight loss.
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Laparoscopic Roux-en-Y gastric bypass vs. laparoscopic sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of lipid effects at one year postsurgery.
Climent, E, Benaiges, D, Pedro-Botet, J, Goday, A, Solà, I, Ramón, JM, Flores-LE Roux, JA, Checa, MÁ
Minerva endocrinologica. 2018;(1):87-100
Abstract
INTRODUCTION Results of the effects of Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG) on triglyceride and high-density lipoprotein (HDL) cholesterol levels are controversial. Moreover, previous meta-analyses focused on global dyslipidemia remission, but did not include the separate remission rates of the different lipid fractions. Hence, the aim of the present meta-analysis was to compare the outcomes (concentration change and remission rates) of GB and SG on diverse lipid disorders one year postbariatric surgery (BS). EVIDENCE ACQUISITION An exhaustive electronic search carried out on MedLine, Embase and The Cochrane Central Register of Controlled Trials (Central) until July 2016 yielded 2621 records, of which 17, totaling 4699 obese patients with one-year follow-up after BS were included in the meta-analysis. EVIDENCE SYNTHESIS GB was superior to SG in terms of total cholesterol (mean difference= 19.77 mg/dL, 95% CI: 11.84-27.69) and low-density lipoprotein (LDL) cholesterol (mean difference: 19.29 mg/dL, 95% CI: 11.93-26.64) decreases as well as in hypercholesterolemia remission (RR: 1.43, 95% CI: 1.27-1.61). No differences were found between GB and SG in terms of HDL cholesterol increase or triglyceride concentration change after surgery, as well as in hypertriglyceridemia and low HDL remission rates. CONCLUSIONS The effect of GB on total and LDL cholesterol concentration decreases and remission was greater than that of SG, whereas no differences were observed with respect to HDL cholesterol and triglyceride concentration evolution. Conclusions cannot be drawn from hypertriglyceridemia and low HDL remission rates based on this meta-analysis.
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Systematic review with network meta-analysis: comparative efficacy of different enteral immunonutrition formulas in patients underwent gastrectomy.
Song, GM, Liu, XL, Bian, W, Wu, J, Deng, YH, Zhang, H, Tian, X
Oncotarget. 2017;(14):23376-23388
Abstract
OBJECTIVES Optimal enteral immunonutrition (EIN) regime for gastric cancer (GC) patients underwent gastrectomy remains uncertainty. To assess comparative efficacy of different EIN formulas in GC patients underwent gastrectomy, we performed network meta-analysis. RESULTS We included 11 RCTs enrolling 840 patients. Pairwise meta-analysis indicated that EIN (RR 0.56, 95% CI 0.36-0.86; MD -0.42, 95% CI -0.74-0.10), Arg+RNA+ω-3-FAs (RR 0.37, 95% CI 0.22-0.63; MD -0.42, 95% CI -0.75-0.07), Arg+Gln+ω-3-FAs (RR 0.22, 95% CI 0.05-0.94; MD -0.69, 95% CI -1.22-1.07) reduced ICs and LOS. Network meta-analysis confirmed the potential of Arg+RNA+ω-3-FAs for ICs (OR 0.27, 95% Crl 0.12-0.49) and Arg+Gln+ω-3-FAs for CIs (OR 0.22, 95% Crl 0.02-0.84) and LOS (SMD -0.63, 95% Crl -1.07-0.13), and indicated that Arg+RNA+ω-3-FAs was superior to Arg+RNA and Arg+Gln for ICs as well. MATERIALS AND METHODS We performed direct and network meta-analyses for randomized controlled trials comparing EIN formulas with each other or standard enteral nutrition (SEN) in reducing infectious complications (ICs), noninfectious complications (NICs) and length of hospital stay (LOS), through January 2016. The surface under the cumulative ranking curve (SCURA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to rank regimes and rate qualities of evidences respectively. CONCLUSIONS As for GC patients underwent gastrectomy, Arg+RNA+ω-3-FAs and Arg+Gln+ω-3-FAs are the optimal regimes of reducing ICs and LOS.
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Systematic Review of Exocrine Pancreatic Insufficiency after Gastrectomy for Cancer.
Straatman, J, Wiegel, J, van der Wielen, N, Jansma, EP, Cuesta, MA, van der Peet, DL
Digestive surgery. 2017;(5):364-370
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Abstract
BACKGROUND Survival rates after a total gastrectomy with adequate lymphadenectomy are improving, leading to a shift in outcomes of interest from survival to postoperative outcomes and symptoms. In this systematic review, we investigate gastrointestinal symptoms that occur after a gastrectomy in relation to exocrine pancreatic insufficiency and the effect of pancreatic exocrine enzyme supplementation on these symptoms. METHODS Online databases PubMed, Embase, and Cochrane Library were systematically searched in accordance with the PRISMA guidelines. Studies that researched gastrointestinal symptoms, exocrine pancreatic function, and enzyme supplementation were identified and assessed. RESULTS The search resulted in a total of 1,023 articles after exclusion of duplicates. After performing a thorough assessment, 4 studies were included for systematic review. Exocrine pancreatic insufficiency was investigated by 2 studies; the results showed a significant decrease of total exocrine pancreatic function of up to 76%. The other 2 studies investigated the effect of pancreatic enzyme supplementation and found minor improvement in fecal consistency and a decrease in high-degree steatorrhea. No differences in individual symptom scores were reported. CONCLUSION Gastrointestinal symptoms such as steatorrhea, bloating, and dumping syndrome may be related to exocrine pancreatic function, initiated by total gastrectomy. Treatment with pancreatic enzymes had a minor positive effect on patients. It should be noted that these studies were of a small sample size and low quality. New and larger RCTs are necessary to either prove or disprove the benefit of pancreatic enzyme replacement therapy in the treatment of the gastrointestinal symptoms after total gastrectomy.
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Current and cutting-edge interventions for the treatment of obese patients.
Vairavamurthy, J, Cheskin, LJ, Kraitchman, DL, Arepally, A, Weiss, CR
European journal of radiology. 2017;:134-142
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Abstract
The number of people classified as obese, defined by the World Health Organization as having a body mass index ≥30, has been rising since the 1980s. Obesity is associated with comorbidities such as hypertension, diabetes mellitus, and nonalcoholic fatty liver disease. The current treatment paradigm emphasizes lifestyle modifications, including diet and exercise; however this approach produces only modest weight loss for many patients. When lifestyle modifications fail, the current "gold standard" therapy for obesity is bariatric surgery, including Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, and placement of an adjustable gastric band. Though effective, bariatric surgery can have severe short- and long-term complications. To fill the major gap in invasiveness between lifestyle modification and surgery, researchers have been developing pharmacotherapies and minimally invasive endoscopic techniques to treat obesity. Recently, interventional radiologists developed a percutaneous transarterial catheter-directed therapy targeting the hormonal function of the stomach. This review describes the current standard obesity treatments (including diet, exercise, and surgery), as well as newer endoscopic bariatric procedures and pharmacotherapies to help patients lose weight. We present data from two ongoing human trials of a new interventional radiology procedure for weight loss, bariatric embolization.
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A Systematic Review: Vitamin D Status and Sleeve Gastrectomy.
Dix, CF, Bauer, JD, Wright, OR
Obesity surgery. 2017;(1):215-225
Abstract
BACKGROUND Bariatric patients regularly present with insufficient vitamin D status before and after surgery, which requires substantial supplementation to treat. This review aims to assess the effect of sleeve gastrectomy on vitamin D status and the effectiveness of vitamin D supplementation. METHODS This review was conducted in accordance with the Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. RESULTS The current guidelines recommend initial vitamin D supplementation of at least 3000 IU/day post-operatively, with no need for follow-up testing after sleeve gastrectomy. Only one study has trialled a dose in line with the recommendations for this patient group. They found that it was effective in improving VitD status. CONCLUSIONS On-going monitoring of vitamin D status is necessary, as the recommended level is not often reached.
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Roux-en-Y gastric bypass versus sleeve gastrectomy: risks and benefits.
Ettleson, MD, Lager, CJ, Kraftson, AT, Esfandiari, NH, Oral, EA
Minerva chirurgica. 2017;(6):505-519
Abstract
INTRODUCTION Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG) are the most commonly performed metabolic surgeries and are highly effective for the treatment of obesity and related comorbidities. In this narrative review, recent studies of at least two years of follow-up directly comparing outcomes between GB and SG are reviewed to assess the efficacy of each procedure in weight loss and diabetes remission, as well as resulting quality of life (QoL) assessment and micronutrient deficiencies. EVIDENCE ACQUISITION A systematic search of the literature of PubMed using MeSH terms and key words was performed. EVIDENCE SYNTHESIS Forty recent studies comparing GB and SG including 208,556 patients are included in this narrative review. Most studies demonstrate significantly greater weight loss after GB compared to SG. There is some evidence that GB may lead to greater proportion of remission of diabetes mellitus (DM), but the majority of studies found no significant difference at longer follow-up. There is some evidence of greater rates of vitamin D and B12 deficiencies following GB. There were no significant differences in QoL assessments between SG and GB. CONCLUSIONS A review of moderate and long-term studies directly comparing SG and GB suggests a greater degree of weight loss with GB. There is some but limited evidence the GB is more likely to induce DM remission, while increasing the risk of specific micronutrient deficiencies.