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Missed Gastric Cancer Metastasis to the Appendix: Case Report and Literature Review.
Alhadid, D, AlShammari, A, Almana, H, Aburahmah, M
The American journal of case reports. 2020;:e920010
Abstract
BACKGROUND Gastric cancer metastasis to the appendix is a rare condition that might present with symptoms of acute appendicitis or remain asymptomatic and be diagnosed incidentally. This report summaries 6 previously reported cases in addition to the presented case. CASE REPORT We report a 54-years-old female patient who presented with gastric cancer metastasis to the appendix that was found incidentally in the second surgery when she underwent bowel resection due to bowel entrapment in internal hernia, a complication of her primary gastric cancer surgical intervention. Six case-reports on gastric cancer metastasis to the appendix were reviewed. The metastasis was symptomatic in 4 cases, and solitary in 3 cases. The diagnosis was delayed in 4 cases as there was no evidence of metastasis at the diagnosis of the primary tumor; appendectomy was performed in all cases. The prognosis of the cases varied considerably. CONCLUSIONS We question the real incidence of appendiceal metastasis in gastric cancer, and the benefit-risk ratio of appendectomy in every gastrectomy. Guidelines on management of similar cases is also needed.
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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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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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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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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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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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Mechanisms of surgical control of type 2 diabetes: GLP-1 is the key factor-Maybe.
Salehi, M, D'Alessio, DA
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2016;(6):1230-5
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Bariatric surgery is the most effective treatment for obesity and diabetes. The 2 most commonly performed weight-loss procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy, improve glycemic control in patients with type 2 diabetes independent of weight loss. One of the early hypotheses raised to explain the immediate antidiabetic effect of RYGB was that rapid delivery of nutrients from the stomach pouch into the distal small intestine enhances enteroinsular signaling to promote insulin signaling. Given the tenfold increase in postmeal glucagon-like peptide-1 (GLP-1) response compared to unchanged integrated levels of postprandial glucose-dependent insulinotropic peptide after RYGB, enhanced meal-induced insulin secretion after this procedure was thought to be the result of elevated glucose and GLP-1 levels. In this contribution to the larger point-counterpoint debate about the role of GLP-1 after bariatric surgery, most of the focus will be on RYGB.
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The effects of enteral immunonutrition in upper gastrointestinal surgery: A systematic review and meta-analysis.
Wong, CS, Aly, EH
International journal of surgery (London, England). 2016;:137-50
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AIM: The beneficial of immunonutrition on overall morbidity and mortality remains uncertain. We undertook a systematic review to evaluate the effects of immune-enhancing enteral nutrition (IEN) in upper gastrointestinal (GI) surgery. METHODS Main electronic databases [MEDLINE via Pubmed, EMBASE, Scopus, Web of Knowledge, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library, and clinical trial registry (ClinicalTrial.gov)] were searched for studies reported clinical outcomes comparing standard enteral nutrition (SEN) and immunonutrition (IEN). The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis was analysed using fixed and random-effects models. RESULTS Nineteen RCTs with a total of 2016 patients (1017 IEN and 999 SEN) were included in the final pooled analysis. The ratio of patients underwent oesophagectomy:gastrectomy:pancreatectomy was 2.2:1.2:1.0. IEN, when administered post-operatively, was associated with a significantly lower risk of wound infection (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.40 to 0.88; p = 0.009) and shorter length of hospital stay (MD -2.92 days, 95% CI -3.89 to -1.95; p < 0.00001). No significant differences in other post-operative morbidities of interest (e.g. anastomotic leak and pulmonary infection) and mortality between the two groups were identified. CONCLUSIONS Overall, our analysis found that IEN decreases wound infection rates and reduces length of stay. It should be recommended as routine nutritional support as part of the Enhanced Recovery after Surgery (ERAS) programmes for upper GI Surgery.
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Totally laparoscopic versus laparoscopic-assisted total gastrectomy for upper and middle gastric cancer: a single-unit experience of 253 cases with meta-analysis.
Chen, K, Pan, Y, Cai, JQ, Wu, D, Yan, JF, Chen, DW, Yu, HM, Wang, XF
World journal of surgical oncology. 2016;:96
Abstract
BACKGROUND Laparoscopic-assisted total gastrectomy (LATG) is the most commonly used methods of laparoscopic gastrectomy for upper and middle gastric cancer. However, totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult, especially for the intracorporeal esophagojejunostomy. We adopted TLTG with various types of intracorporeal esophagojejunostomy. In this study, we compared LATG and TLTG to evaluate their outcomes. METHODS From March 2006 to September 2015, 253 patients with upper and middle gastric cancer underwent laparoscopic total gastrectomy (LTG), 145 patients underwent LATG, and 108 patients underwent TLTG. The clinicopathological characteristics and postoperative outcomes were retrospectively compared between the two groups. Furthermore, a systematic review and meta-analysis were conducted. RESULTS The operation time and estimated blood loss were similar between the groups. There were no significant differences in first flatus, diet initiation, and postoperative hospital stay. The surgical complication rates were 17.2% (25/145) and 13.9% (15/108) in the LATG and TLTG groups, respectively. The meta-analysis also revealed no significant differences in the operation time, estimated blood loss, time to first flatus, length of hospital stay, overall, and anastomosis-related complications among the groups. CONCLUSIONS TLTG is a feasible choice for gastric cancer patients, with comparable results to the LATG approach.
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Long-term clinical outcomes of laparoscopy-assisted distal gastrectomy versus open distal gastrectomy for early gastric cancer: A comprehensive systematic review and meta-analysis of randomized control trials.
Lu, W, Gao, J, Yang, J, Zhang, Y, Lv, W, Mu, J, Dong, P, Liu, Y
Medicine. 2016;(27):e3986
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The objective of this study was to compare long-term surgical outcomes and complications of laparoscopy-assisted distal gastrectomy (LADG) with open distal gastrectomy (ODG) for the treatment of early gastric cancer (EGC) based on a review of available randomized controlled trials (RCTs) evaluated using the Cochrane methodology.RCTs comparing LADG and ODG were identified by a systematic literature search in PubMed, Cochrane Library, MEDLINE, EMBASE, Scopus, and the China Knowledge Resource Integrated Database, for papers published from January 1, 2003 to July 30, 2015. Meta-analyses were performed to compare the long-term clinical outcomes.Our systematic literature search identified 8 eligible RCTs including 732 patients (374 LADGs and 358 ODGs), with low overall risk of bias. Long-term mortality and relapse rate were comparable for both techniques. The long-term complication rate was 8.47% in LADG groups and 13.62% in the ODG group, indicating that LADG was associated with lower risk for long-term complications (RR = 0.63; 95%CI = 0.39-1.00; P = 0.03).In the treatment of EGC, LADG lowered the rate of long- and short-term complications and promoted earlier recovery, with comparable oncological outcomes to ODG.