Antanas Mickevicius

A steady decline in gastric cancer mortality rate over the last few decades is observed in Western Europe. However it is still not clear if this trend applies to Eastern Europe where high incidence rate of gastric cancer is observed. This was a retrospective non-randomized, single center, cohort study. During the study period 557 consecutive patients diagnosed with gastric cancer in which curative operation was performed met the inclusion criteria. The study population was divided into two groups according to two equal time periods: 01-01-1994 – 31-12-2000 (Group I – 273 patients) and 01-01-2001 – 31-12-2007 (Group II – 284 patients). Primary (five-year survival rate) and secondary (postoperative complications, 30-day mortality rate and length of hospital stay) endpoints were evaluated and compared. Rate of postoperative complications was similar between the groups, except for Grade III (Clavien-Dindo grading system for the classification of surgical complications) complications that were observed at significantly lower rates in Group II (26 (9.5%) vs. 11 (3.9%), p = 0.02). Length of hospital stay was significantly (p = 0.001) shorter (22.6 ± 28.9 vs. 16.2 ± 17.01 days) and 30-day mortality was significantly (p = 0.02) lower (15 (5.5%) vs. 4 (1.4%)) in Group II. Similar rates of gastric cancer related mortality were observed in both groups (92.3% vs. 90.7%). However survival analysis revealed significantly (p = 0.02) better overall 5-year survival rate in Group II (35.6%, 101 of 284) than in Group I (23.4%, 64 of 273). There was no difference in 5-year survival rate when comparing different TNM stages. Gastric cancer treatment results remain poor despite decreasing early postoperative mortality rates, shortening hospital stay and improved overall survival over the time. Prognosis of treatment of gastric cancer depends mainly on the stage of the disease. Absence of screening programs and lack of clinical symptoms in early stages of gastric cancer lead to circumstances when most of the patients presenting with advanced stage of the disease can expect a median survival of less than 30 months even after surgery with curative intent.

Respiratory function deteriorates over time after lung transplant. Reflux disease with pulmonary complications is a possible cause of this decline. This case series we aim to assess whether respiratory function improves after Nissen fundoplication in lung transplant patients and if surgery reduces gastroesophageal reflux disease (GERD) symptoms and use of proton pump inhibitors (PPIs). A retrospective case series of lung transplant patients with reflux disease and Nissen fundoplication. Clinical symptoms, pH-metry data, use of PPIs were recorded before the procedure and up to 18 months postoperatively. The FEV1 values before and after Nissen fundoplication were recorded at 3 monthly intervals. Patients' satisfaction scores were recorded before operation and postoperatively. A total of 64 lung transplant patients were selected. After Nissen fundoplication, the pH studies were done on 26 patients. The mean overall acid exposure fraction was 1.03% (P<0.05). FEV1 declined for 6 months postoperatively and then gradually improved. The comparison of FEV1 at 3 months preoperatively to 3 months postoperatively showed no significant difference (P=0.067) as well as at 6 months. A significant improvement in clinical GERD symptoms was achieved after antireflux surgery; however, the patients remained receiving PPIs. NF has been established as a safe operation for lung transplant patients. Late Nissen fundoplication did not improve lung function significantly amongst lung transplanted patients; however, patients with symptomatic GERD may have benefited from Nissen fundoplication in terms of symptom relief. A multicenter randomized control trial is needed to assess the effect of early unselected reflux control on respiratory function and graft survival.

Long-term results in antireflux surgery may depend on fundoplication type and wrap length. We compared the outcome of two different wrap lengths among the patients undergoing partial or total fundoplications. This study is the next part of a prospective 5-year follow-up assessment. A total of 153 patients were randomized to Nissen or Toupet 1.5- or 3-cm wrap laparoscopic fundoplication. The primary endpoint—treatment failure rate was defined as a recurrent GERD or persistent dysphagia. Intensity of heartburn, dysphagia, gas-bloating, presence of esophagitis were assessed as a secondary outcome at 1-year and 5-year follow-up. At 5-year follow-up, data were collected from 129 (85 %) patients. At 1-year follow-up, 17 (11 %) treatment failures were detected. At the end of the fifth year, the numbers reached 23 (15 %). The failures were more common in the 1.5-cm Toupet (25 %) and the 3-cm Nissen group (18.2 %). The significant difference in failure rates was found between 1.5-cm and 3-cm Toupet groups (P < 0.05). Dysphagia remained low during the follow-up in all of the groups. The prevalence of higher scores of heartburn after 5 years was detected in Nissen 1.5-cm group (20.8 %). The lowest scores were observed in Toupet 3-cm group. Bloating symptoms were more prevalent among Nissen and Toupet 3-cm group patients at 5-year follow-up. At the end of the fifth year, the prevalence of esophagitis was lower in Nissen 1.5-cm (19.3 %) and Toupet 3-cm (13.3 %) groups. The highest prevalence of esophagitis—32.4 %—was found in Toupet 1.5-cm group. Nissen and Toupet fundoplication achieved sufficient control of reflux with success rate of 85 % at 5-year follow-up. There were no significant differences in the postoperative dysphagia, esophagitis, and bloating rates. However, the distribution of treatment failures leads us to conclude that 1.5-cm wrap length is insufficient in cases of posterior partial fundoplication.

Incontinence or hypercontinence of the fundic wrap depends primarily on the length of the valve or the type of procedure. Much less attention has been paid to the fundic wrap length. This study aimed to compare the effectiveness of two different wrap lengths among the patients undergoing partial or total fundoplication. For this study, 153 patients were randomized to either Nissen (1.5- or 3-cm wrap) or Toupet (1.5- or 3-cm wrap) laparoscopic fundoplication. The groups were compared according to intensity of dysphagia, esophageal manometry data, ambulatory 24-h pH monitoring data, postoperative esophagitis rate, and overall treatment failure rate. In all the groups, the tone of the lower esophageal sphincter was significantly increased and the DeMeester score significantly decreased, reaching normal levels. At 6 months after surgery, the Toupet 1.5-cm group had significantly more cases of esophagitis than the 3-cm wrap group (24.2% vs 3.3%; p < 0.05). At 12 months after surgery, only one patient in the Nissen 3-cm group had moderate to severe dysphagia. In all cases, failures were associated with persistent erosive esophagitis. At the 12-month follow-up assessment, treatment failures were significantly more common in Toupet 1.5-cm group than in the Toupet 3-cm group (17.5% vs 2.7%; p < 0.05). However, such differences were not observed in the Nissen groups (7.8% for 1.5 cm and 15.6% for 3 cm; p > 0.05). Evaluation of the treatment results suggests that the wrap length is important in partial Toupet fundoplication to avoid treatment failures. The 3-cm wrap is superior to the 1.5-cm wrap in cases of partial posterior Toupet fundoplication. The influence of wrap length on treatment failure remains unconfirmed for the Nissen procedure.