The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field.
This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent.
This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool “propagate segmentation”, and all muscle seen in the image was manually adjusted.
We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76–0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04–8.15).
Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.
Pancreaticopleural fistula is a rare complication of chronic pancreatitis.
To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic.
Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected.
The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections.
Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.
In 1994 Cucchi et al.7 first published a paper identifying gastrogastric fistulas (GGF) as a complication of open divided Roux-en-Y gastric bypass (RYGB). The findings showed that GGF develop regardless of the remnant division from the pouch. Some authors attribute GGF to technical failure, early postoperative leaks or even marginal ulcers. Furthermore, diagnosis is usually difficult and requires a high index of suspicion, mainly due to a lack of pathognomonic symptoms and signs14. As of today, there is no consensus regarding an optimal diagnostic pathway for GGF, and management is usually patient tailored13,14.
In this paper, we present a case of a lady treated at our centre with recurrent GGF, and provide an up-to-date literature review of the topic.
Woman of 42 year-old with a BMI of 44 kg/m2 underwent a previous anti-gastric anti-colic RYGB using a circular staple for the gastro-jejunostomy anastomosis (GJA) in Jaber Hospital, Kuwait. Intra-operatively the anvil had an incomplete anastomotic stapler doughnut; however, both the intra-operative methylene blue and air tests were negative. The anastomotic line was the buttressed with 2-0 absorbable sutures. Two days post-operatively the patient developed acute abdominal pain, tachycardia and fever, with a water-soluble contrast study suggesting a GJA leak. A subsequent diagnostic laparoscopy however, was unremarkable, and she was managed conservatively. Seven years later, she again presented complaining of a two month history of progressive epigastric and retrosternal chest pain. Blood investigations showed mild leucocytosis and hyper-amylasemia. Gastroscopy demonstrated bile entry to the gastric pouch, with a corresponding 6-7 mm GGF. A barium swallow confirmed GGF, with no other fistulas nor strictures. She was managed endoscopically with one endo-clip applied to GGF, and its edges were burned using argon plasma coagulation.
After three years she was attended again with abdominal pain and distention, associated with weight regain and vomiting. A barium swallow confirmed recurrence of the fistula (Figure 1), and gastroscopy showed a large fistulous opening measuring 15-20 mm, not feasible for endoscopic intervention.
Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks.
Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks.
Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT.
Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution.
MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.
Desenvolvido por Surya MKT